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

Abstract

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

Conscious sedation for awake fibreoptic intubation: a review of the literature

“…9,10,[14][15][16] More recently, case reports have described the concurrent use of propofol TCI with remifentanil TCI for AFOI [14][15][16] Authors describing the combined use of TCI propofol and remifentanil for AFOI have reported mean effect-site concentrations during the procedure of 0.8-2.0 lgÁmL -1 and 1.5-3.2 ngÁmL -1 , respectively. Although there is no evidence supporting the superiority of TCI propofol over a fixed rate infusion in the setting of an AFOI, it is safe to say that a TCI has a more consistent pharmacodynamic effect and may allow for a more predictable level of sedation to be maintained.…”

“…[20][21][22][23][24] This makes it an attractive drug of choice for the intensely stimulating but usually brief airway manipulation during an AFOI. It is increasingly being used either as the primary agent or in conjunction with midazolam 10,11,25 and, more recently, propofol [14][15][16] to provide sedation during AFOI. Studies evaluating remifentanil as a primary agent have described its use at different set rates of infusion, by bolus dose followed by infusion, and, more recently as a TCI.…”

“…34 More recently, remifentanil has been used in combination with propofol in an attempt to reduce recall and minimize respiratory complications. [14][15][16] Moerman et al investigated the combination of TCI propofol with either TCI remifentanil or a manual infusion of remifentanil in 60 patients undergoing sedation for colonoscopy. 30 Notwithstanding the obvious differences between this procedure and an airway endoscopy, Moerman et al showed that TCI remifentanil resulted in a reduction in the doses of propofol and a lower incidence of apnea and respiratory depression compared with a manually controlled infusion of remifentanil.…”

“…Surprisingly, they reported coughing in 60% of patients and increases in heart rate and blood pressure of 22% and 28%, respectively, but 85% of patients had no recall of the procedure. 16 Three studies have looked at the use of remifentanil required for AFOI in the absence of any other sedatives and without application of local anesthetic to the larynx. 12,35,36 Under these conditions, Vennila et al found that the mean effect-site concentrations of remifentanil required for fibreoptic endoscopy and railroading of the tracheal tube were 6.3 ngÁmL -1 and 8.06 ngÁmL -1 , respectively.…”

Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations

“…4,13,20 A cogent plan for intubation based on preoperative airway assessment should be discussed with the anesthesia team. 5,26 Plans for administration of antibiotics, hormone replacement, pretreatment with somatostatin analogs, 8 or any additional perioperative medications should also be addressed in advance. It is imperative that the correct neuroimaging modalities are used and that the studies are carefully and systematically reviewed preoperatively.…”