The place for short-acting opioids: special emphasis on remifentanil

Pain is among the worst possible experiences for the critically ill. Therefore, nearly all intensive care patients receive some kind of pain relief, and opioids are most frequently administered. Morphine has a number of important adverse effects, including histamine release, pruritus, constipation, and, in particular, accumulation of morphine-6-glucuronide in patients with renal impairment. Hence, it is not an ideal analgesic for use in critically ill patients. Although the synthetic opioids fentanyl, alfentanil, and sufentanil have better profiles, they undergo hepatic metabolism and their continuous infusion also leads to accumulation and prolonged drug effects. Various attempts have been made to limit these adverse effects, including daily interruption of infusion of sedatives and analgesics, intermittent bolus injections rather than continuous infusions, and selection of a ventilatory support pattern that allows more spontaneous ventilation. However, these techniques at best only limit the effects of drug accumulation, but they do not solve the problem. Another type of approach is to use remifentanil in critically ill patients. Remifentanil is metabolized by unspecific blood and tissue esterases and undergoes rapid metabolism, independent of the duration of infusion or any organ insufficiency. There are data indicating that remifentanil can be used for analgesia and sedation in all kinds of adult intensive care unit patients, and that its use will result in rapid and predictable offset of effect. This may permit both a significant reduction in weaning and extubation times, and clear differentiation between over-sedation and brain dysfunction. This article provides an overview of the use of short-acting opioids in the intensive care unit, with special emphasis on remifentanil. It summarizes the currently available study data regarding remifentanil and provides recommendations for clinical use of this agent

Effects of different remifentanil doses on the stress reaction and BIS value of video laryngoscope-guided tracheal intubation

Purpose: To explore the affinity of different remifentanil doses for  intravenous anesthesia in video laryngoscope-guided tracheal intubation.Methods: Eighty patients who required anesthesia for elective non-ophthalmic surgery were included. They were divided into four groups (A, B, C and D) and received a different dose of either 1, 1.5, or 2 μg/kg remifentanil or a dose of 2 μg/kg fentanyl, respectively. An anesthetic state was achieved and maintained by administration of 3 - 5 mg/kg propofolum and 0.1 - 0.3 mg/kg remifentanil. The mean value of the various indices, including arterial pressure (MAP), bispectral index and heart rate (HR) wererecorded prior to anesthesia induction (T0), prior to intubation (T1),  instantly before intubation (T2), and at 1 (T3), 3 (T4) and 5 (T5) after the intubation. Cortisol concentration was measured at T0, T1 and T5.Results: Remifentanil (1 μg/kg) induced a moderate increase in HR and MAP at T3 compared with fentanyl. HR and MAP in the lower dose group were significantly higher than those in groups B and C at T3. Compared to T1, the concentrations of cortisol decreased after anesthesia and then significantly increased during tracheal intubation. Cortisol concentration in group B was the lowest at T5.Conclusion: The most effective concentrations of remifentanil are 1 and 1.5 μg/kg for anesthesia induction and tracheal intubation, respectively.Keywords: Remifentanil, Stress reaction, Bispectral index, Video laryngoscope, Tracheal intubatio

Closed-loop control of anesthesia : survey on actual trends, challenges and perspectives

Automation empowers self-sustainable adaptive processes and personalized services in many industries. The implementation of the integrated healthcare paradigm built on Health 4.0 is expected to transform any area in medicine due to the lightning-speed advances in control, robotics, artificial intelligence, sensors etc. The two objectives of this article, as addressed to different entities, are: i) to raise awareness throughout the anesthesiologists about the usefulness of integrating automation and data exchange in their clinical practice for providing increased attention to alarming situations, ii) to provide the actualized insights of drug-delivery research in order to create an opening horizon towards precision medicine with significantly improved human outcomes. This article presents a concise overview on the recent evolution of closed-loop anesthesia delivery control systems by means of control strategies, depth of anesthesia monitors, patient modelling, safety systems, and validation in clinical trials. For decades, anesthesia control has been in the midst of transformative changes, going from simple controllers to integrative strategies of two or more components, but not achieving yet the breakthrough of an integrated system. However, the scientific advances that happen at high speed need a modern review to identify the current technological gaps, societal implications, and implementation barriers. This article provides a good basis for control research in clinical anesthesia to endorse new challenges for intelligent systems towards individualized patient care. At this connection point of clinical and engineering frameworks through (semi-) automation, the following can be granted: patient safety, economical efficiency, and clinicians' efficacy

Anesthetic Management of Rapid Ventricular Response Atrial Fibrillation in an Elderly Woman Using Remifentanil; A Case Report

Atrial fibrillation (AF) is the most common cardiac Arrhythmia in all clinical settings. In the setting of atrial fibrillation with rapid ventricular response (AFib with RVR), early rate control (with or without restoration of the sinus rhythm) is the center of management. Several drugs are used for the management of rapid ventricular response AF but the optimal one is unknown yet. In this case report we present an elderly woman undergoing urgent ophthalmic surgery whose rapid ventricular response AF was controlled by Remifentanil

General Anesthesia as a Multimodal Individualized Clinical Concept

In this book, a series of modern multimodal monitoring techniques during general anesthesia are presented, with a focus on patient-oriented anesthesia based on the individual needs of each patient reflected in the degree of hypnosis, the nociception–antinociception balance, and neuromuscular transmission. Moreover, a series of secondary implications for hemodynamic status, post-anesthetic recovery, and patient satisfaction are highlighted

Clinical Recommendations for Non-Anesthesia Healthcare Providers Performing Emergency Airway Management Outside the Operating Room

Emergency endotracheal intubations occurring outside of the Operating Room (OR) are often performed by non-anesthesia providers. At a large, urban, level one trauma center, the current airway management policy for these non-anesthesia providers does not follow best practices based on the literature. Specifically, some non-anesthesia providers are not credentialed and/or privileged to administer neuromuscular blocking agents (NMBAs) during emergency endotracheal intubations. The purpose of this project was to develop evidence-based clinical recommendations for emergency airway management outside of the OR. The following objectives are framed using the Johns Hopkins Evidence-Based Practice (EBP) Model and were established to achieve the projects overall aim: 1) synthesize the evidence around the use of NMBAs during emergency airway management, 2) develop evidence-based recommendations for emergency airway management training, and 3) develop a comprehensive plan on how to enact and monitor recommendations for effectiveness. This project was significant because it provided a blueprint for clinical practice changes that could be adopted and implemented to improve patient outcomes. The project created evidence-based recommendations to optimize outcomes and enhance training for these providers requiring credentialing. In addition, the project included the development of a plan to monitor and measure the recommendations for effectiveness, as well as the development of a plan for adjusting/changing recommendations if identified as ineffective. These plans are outside the scope of the project’s academic/curricular timeline and would be implanted by the facility

Opioid-Sparing Anesthesia in Cardiac Surgery Requiring Cardiopulmonary Bypass

Background: Traditional anesthesia for cardiac surgery involved high opioid use associated with adverse events and poor outcomes which led to the adoption of multi-modal analgesic approaches. Although improvements in the overall opioid consumption are seen with multi- modal analgesic approaches, recent studies in opioid-sparing anesthesia and regional anesthesia can further reduce the operative use of opioids in cardiac surgery to improve patient outcomes. Methods: A comprehensive study search was conducted using CINAHL and MEDLINE (ProQuest) to identify research studies from the past three years that have focused on opioid- sparing anesthesia or opioid-free techniques in patients undergoing cardiac surgery with cardiopulmonary bypass. Results: Six research studies were identified as relevant for review. The studies included in this literature review address opioid-sparing anesthesia in cardiac surgery through different techniques, investigate the feasibility for implementation, the role of regional anesthesia, and individual intraoperative pharmacological adjuvants in cardiac surgery requiring cardiopulmonary bypass (CPB). Keywords: Opioid-sparing anesthesia, cardiac surgery, cardiac anesthesia, cardiopulmonary bypass, regional anesthesia, opioid crisis, dexmedetomidine

Racemic ketamine in adult head injury patients: use in endotracheal suctioning

INTRODUCTION: Endotracheal suctioning (ETS) is essential for patient care in an ICU but may represent a cause of cerebral secondary injury. Ketamine has been historically contraindicated for its use in head injury patients, since an increase of intracranial pressure (ICP) was reported; nevertheless, its use was recently suggested in neurosurgical patients. In this prospective observational study we investigated the effect of ETS on ICP, cerebral perfusion pressure (CPP), jugular oxygen saturation (SjO2) and cerebral blood flow velocity (mVMCA) before and after the administration of ketamine. METHODS: In the control phase, ETS was performed on patients sedated with propofol and remifentanil in continuous infusion. If a cough was present, patients were assigned to the intervention phase, and 100 \u3b3/kg/min of racemic ketamine for 10 minutes was added before ETS. RESULTS: In the control group ETS stimulated the cough reflex, with a median cough score of 2 (interquartile range (IQR) 1 to 2). Furthermore, it caused an increase in mean arterial pressure (MAP) (from 89.0\u2009\ub1\u200911.6 to 96.4\u2009\ub1\u200913.1 mmHg; P <0.001), ICP (from 11.0\u2009\ub1\u20096.7 to 18.5\u2009\ub1\u20098.9 mmHg; P <0.001), SjO2 (from 82.3\u2009\ub1\u20097.5 to 89.1\u2009\ub1\u20095.4; P\u2009=\u20090.01) and mVMCA (from 76.8\u2009\ub1\u200920.4 to 90.2\u2009\ub1\u200930.2 cm/sec; P\u2009=\u20090.04). CPP did not vary with ETS. In the intervention group, no significant variation of MAP, CPP, mVMCA, and SjO2 were observed in any step; after ETS, ICP increased if compared with baseline (15.1\u2009\ub1\u20099.4 vs. 11.0\u2009\ub1\u20096.4 mmHg; P <0.05). Cough score was significantly reduced in comparison with controls (P <0.0001). CONCLUSIONS: Ketamine did not induce any significant variation in cerebral and systemic parameters. After ETS, it maintained cerebral hemodynamics without changes in CPP, mVMCA and SjO2, and prevented cough reflex. Nevertheless, ketamine was not completely effective when used to control ICP increase after administration of 100 \u3b3/kg/min for 10 minutes