Optimizing the surgical field in pediatric functional endoscopic sinus surgery: a new evidence-based approach. Comparative effects of propofol versus fentanyl on cerebral oxygenation state during normothermic cardiopulmonary bypass and postoperative cognitive dysfunction. [The effect of encephalogram bispectral index monitoring during total intravenous anesthesia with propofol in outpatient surgery]. Target-controlled versus manually-controlled infusion of propofol for direct laryngoscopy and bronchoscopy.
To conduct the first prospective randomized controlled study 1) evaluating the possibility of improving the quality of the operative field and to provide a bloodless functional endoscopic sinus surgery (FESS) in children through total intravenous anesthesia (TIVA) using remifentanil combined with propofol, and 2) testing the safety and efficacy of remifentanil in propofol-TIVA in inducing controlled hypotension in children at a target mean arterial blood pressure of 50 mm Hg.
                Randomized controlled trial.
                General hospital.
                Seventy children underwent FESS under hypotensive general anesthesia with equal randomization into two groups. Group I received TIVA with remifentanil, whereas group II had balanced anesthesia (BA) with esmolol. Heart rate, blood pressure, operative time, blood loss, and quality of the surgical conditions were recorded.
                Intraoperative blood loss in the TIVA group was less than in the BA group. The quality and dryness of the surgical field in both the visual analogue scale and the six-point scale was significantly better in the TIVA group than in the BA group. Hypotension was sustained at the target mean arterial blood pressure of 50 mm Hg in the two groups, without any significant difference.
                Improving the quality of the surgical field and providing a bloodless FESS in children is attainable with TIVA. TIVA using a combination of remifentanil and propofol is superior to BA, even with the use of additional potent hypotensive agents such as esmolol. Both techniques are safe and effective in inducing controlled hypotension in children at a target mean arterial blood pressure of 50 mm Hg. The purpose of this study was to examine the comparative effects of propofol and fentanyl on cerebral oxygenation during normothermic cardiopulmonary bypass and postoperative cognitive dysfunction.
                One hundred eighty patients scheduled for elective coronary artery bypass grafting were randomly divided into two groups: propofol group (n = 90) and fentanyl group (n = 90). After induction of anesthesia, a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb to monitor jugular venous oxygen hemoglobin saturation continuously. Hemodynamic measurements and arterial and jugular venous blood gases were measured at seven time points. All patients underwent a battery of neurologic and neuropsychological tests on the day before the operation and at 6 months after the operation.
                Cerebral desaturation (defined as a jugular venous oxygen hemoglobin saturation value less than 50%) during cardiopulmonary bypass was more frequent in the fentanyl group than in the propofol group. Cerebral desaturation time (duration when jugular venous oxygen hemoglobin saturation was less than 50%) and the ratio of cerebral desaturation time to total cardiopulmonary bypass time in the fentanyl group differed significantly from those in the propofol group (fentanyl group: 27 +/- 14 minutes, 20% +/- 9%; propofol group: 18 +/- 11 minutes, 14% +/- 7%, respectively, p < 0.05). There was no significant difference in postoperative cognitive dysfunction at 6 months after operation between the two groups (propofol group: 5 of 77, 6%; fentanyl group: 5 of 75, 7%).
                Propofol preserved cerebral oxygenation state estimated by jugular venous oxygenation during cardiopulmonary bypass compared with the fentanyl group. However, propofol did not affect postoperative cognitive dysfunction. To assess the effect of monitoring the encephalogram bispectral index (BIS) during outpatient surgery. Outcome measures were amount of propofol administered, awakening and discharge.
                Forty consecutive outpatient surgery patients were studied. The patients gave informed consent and received general intravenous anesthesia with propofol administered through a laryngeal mask using a computerized system (Diprifusor(R)). Two groups were formed: in group A, BIS was monitored, although the information was hidden from the anesthesiologists, who used the usual signs (loss of blinking reflex, pupil size and hemodynamic response) to guide anesthesia; in group B the anesthesiologists used BIS monitoring to guide propofol administration. Measurements were blood pressure, heart rate and BIS at six times during the procedure (T1-T6). Other data recorded were age, weight, height, propofol consumption in relation to weight and duration of procedure, consumption of rocuronium and alfentanil, duration of propofol infusion, time from withdrawal of propofol until eye opening, duration of stay in the post-anesthesia intensive care unit and time until total recovery. A questionnaire assessed the presence of intraoperative awareness and degree of satisfaction. The data were analyzed by Student's t and a chi square tests, with statistical significance at p < 0.05.
                Demographic variables (age, weight and height) were similar, as were duration of propofol infusion, total dose of alfentanil and rocuronium, evolution of blood pressure and heart rate. Statistically significant differences in BIS were observed at two times, T4 and T5; total propofol administered was 32.6% lower in group B; and time until eye opening was significantly shorter in group B. No significant differences were observed for time until full recovery. No instances of intraoperative awareness were reported and satisfaction was high in both groups.
                BIS monitoring allows for propofol titration that leads to a mean reduction of 32.6% in consumption, shortening the time until eye opening without causing intraoperative awareness or reducing patient satisfaction. Few studies have compared the clinical profile of target-controlled infusions of propofol with that of manually-controlled infusions. Fifty-four ASA physical status I or II patients scheduled for an elective otorhinolaryngology endoscopy performed under general anesthesia with spontaneous ventilation were enrolled in this prospective randomized study to compare the clinical outcome of such administrations. Before induction, all patients received a single alfentanil bolus dose (10 microg/kg). Propofol administration was adapted to maintain absence of movement, hemodynamic stability, and efficient spontaneous ventilation. When compared with the Manually-Controlled Infusion group, in the Target-Controlled Infusion group there were fewer movements at insertion of the laryngoscope (14.8% vs. 44.4%), improved hemodynamic stability (largest variations of mean arterial blood pressure <10% of control values, versus 20%), fewer episodes of apnea, and less respiratory acidosis after endoscopy (pH = 7.37 +/- 0.05 and PaCO(2) = 50 +/- 7 mm Hg versus pH = 7.28 +/- 0.06 and PaCO(2) = 58 +/- 9 mm Hg); the recovery was also shorter (time to opening eyes or verbal response, 4.6 +/- 2.0 min and 6.8 +/- 2.5 min versus 10.8 +/- 7.3 min and 15.7 +/- 7.1 min). Propofol consumption was comparable in the two groups. Targeting the effect-site concentration improved the time course of the propofol drug effect during direct laryngoscopy performed during spontaneous ventilation when compared with manual infusion.
                This study compares the clinical profile of propofol anesthesia for direct laryngoscopy with spontaneous ventilation when the drug is administered either as a manually controlled infusion or by targeting the effect-site concentration through a target-controlled infusion (TCI) device. TCI improves the time course of propofol effects.
Using propofol to achieve deliberate hypotension may improve the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and operation time. RCTs with good quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.