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Purpose This prospective, double-blind, placebo-controlled study was designed to determine the efficacy of nitrous oxide ([N.sub.2]O) in alleviating the pain that followed sequential injection of propofol and rocuronium. Methods A total of 205 adult patients (age, 18-68 years) received one of the following combinations: NaCl and 100% [O.sub.2] (group C); 0.5 mg/kg lidocaine and 100% [O.sub.2] (group L); NaCl and a mixture of 67% [N.sub.2]O / [O.sub.2] (group N); or 0.5 mg/kg lidocaine and a mixture of 67% [N.sub.2]O/[O.sub.2] (group LN). Vein occlusion was released after 1 min, and 5 ml propofol was injected over 10 s. Pain was evaluated on a visually enlarged, laminated, numeric rating (0-10) scale. The remainder of the induction dose of propofol (with a 3-ml bolus of normal saline and 0.6 mg/kg rocuronium) was then injected. The response to the rocuronium injection was assessed with a four-point scale (0-3). Results The incidence and severity of pain from the propofol injection in groups L, N, and LN were significantly lower than those in group C (P < 0.001). Frequency and intensity of the withdrawal response were significantly less in groups N and LN than in groups C and L (no response, P < 0.001; severe response, P < 0.001). Conclusions Pretreatment with inhaled [N.sub.2]O can reduce the pain associated with propofol and rocuronium injection. Moreover, [N.sub.2]O (with or without lidocaine) is more effective than lidocaine alone in reducing rocuronium-related withdrawal reactions associated with sequential injection of propofol and rocuronium. Keywords Nitrous oxide * Pain * Propofol * Rocuronium, Introduction Propofol is a popular anesthesia induction drug because of its quick onset of action and smooth recovery. Rocuronium is an amino-steroidal, nondepolarizing muscle relaxant with an intermediate duration of [...]

Purpose Although attenuation of tube-induced coughing is necessary in specific types of surgery, the best method for such attenuation is still unclear. We studied the combined intervention of endotracheal lidocaine and intravenous remifentanil compared to intravenous remifentanil alone with respect to coughing during emergence from anesthesia. Methods We examined 60 ASA 1-2 patients (age, 20-69 years) undergoing tympanoplasty under general anesthesia. Anesthesia was induced with propofol, remifentanil, and rocuronium. The trachea was intubated using a laryngotracheal instillation of topical anaesthetic (LITA) tracheal tube. Anesthesia was maintained with propofol and remifentanil (0.1-0.3 µg/kg/min). Propofol was discontinued and remifentanil (0.1 µg/kg/min) was continued at the end of the operation. Patients were randomly allocated to the lidocaine (n = 30) and control groups (n = 30). We administered 3 ml 4% lidocaine via the LITA tube to patients in lidocaine group at the end of the operation. The trachea was extubated when the patient regained consciousness and followed orders. Coughing was evaluated using a 4-point scale by an observer who examined the video records at extubation. Results Fewer patients in lidocaine group (8 of 30) than in control group (18 of 30, p < 0.01) coughed. Fewer patients in lidocaine group (2 of 30) than in control group (12 of 30, p < 0.01) had moderate or severe cough (scale 2 or 3). Conclusions This study is consistent with the finding that endotracheal lidocaine administration and continuous infusion of remifentanil before extubation is useful to prevent coughing on emergence from anesthesia. Keywords Anesthetics local, lidocaine * Anesthetic techniques, i.v. infusion * Analgesics opioid, remifentanil * Complications, extubation tracheal, Introduction Tube-induced coughing is observed during emergence from anesthesia. In tympanoplasty, middle ear pressure may increase because of tube-induced coughing and severe head movement and thereby cause adverse effects for [...]

Purpose To compare two protocols for sedation and analgesia during therapeutic hypothermia: midazolam and fentanyl versus propofol and remifentanil. The primary outcome was the time from discontinuation of infusions to extubation or decision not to extubate (offset time). Secondary outcomes were blood pressure, heart rate, use of vasopressors and inotropic drugs, pneumonia and neurological outcome. Methods This was an open, randomised, controlled trial on 59 patients treated with therapeutic hypothermia (33-34 °C for 24 h) after cardiac arrest in two Norwegian university hospitals between April 2008 and May 2009. The intervention was random allocation to sedation and analgesia with propofol/remifentanil or midazolam/fentanyl. Results Twenty-nine patients received propofol and remifentanil, and 30 midazolam and fentanyl. Baseline characteristics were similar. Sedation and analgesia were stopped in 35 patients, and extubation was performed in 17 of these. Sedation had to be continued for 24 patients. Time to offset was significantly lower in patients given propofol and remifentanil [mean (95 % confidence intervals) 13.2 (2.3-24) vs. 36.8 (28.5-45.1) h, respectively, p < 0.001]. Patients given propofol and remifentanil needed norepinephrine infusions twice as often (23 vs. 12 patients, p = 0.003). Incidence of pneumonia and 3-month neurological outcome were similar in the two groups. Conclusions Time to offset was significantly shorter in patients treated with propofol and remifentanil. However, the clinical course in 40 % of patients prevented discontinuation of sedation and potential benefits from a faster recovery. The propofol and remifentanil group required norepinephrine twice as often, but both protocols were tolerated in most patients., Author(s): Thor W. Bjelland [sup.1], Ola Dale [sup.1] [sup.2], Kjell Kaisen [sup.4], Bjørn O. Haugen [sup.1] [sup.3], Stian Lydersen [sup.5], Kristian Strand [sup.4], Pål Klepstad [sup.1] [sup.2] Author Affiliations: (1) [...]

Surgical stress and anesthesia result in systemic immunosuppression. Propofol, a commonly used anesthetic agent, alters immune cell functions. Previously, we demonstrated that extracellular pressure increases macrophage phagocytosis. We hypothesized that propofol might influence pressure-induced macrophage phagocytosis in monocytes from patients undergoing surgery. Pressure (20 mmHg above ambient pressure) augmented phagocytosis in monocytes from non-propofol-anesthetized patients but reduced phagocytosis in monocytes from propofol-anesthetized patients. In vitro, propofol stimulated phagocytosis but reversed pressure-induced phagocytosis in THP-1 macrophages and monocytes from healthy volunteers. The [GABA.sub.A] receptor antagonists picrotoxin and SR-95531 did not affect basal THP-1 phagocytosis or prevent pressure-stimulated phagocytosis. However, picrotoxin and SR-95531 negated the inhibitory effect of pressure in propofol-treated cells without altering propofol-induced phagocytosis. Phosphorylation of the adaptor protein p130cas was inversely related to phagocytosis: it was inhibited by pressure or propofol but increased by pressure + propofol compared with propofol alone. Reduction of p130cas by small interfering RNA in THP-1 macrophages increased basal phagocytosis and prevented pressure and propofol effects. In conclusion, propofol may alter macrophage responses to pressure via the GABAA receptor and p130cas, whereas pressure also acts via p130cas but independently of [GABA.sub.A] receptors, p130cas may be an important target for modulation of macrophage function in anesthetized patients. anesthesia; mechanotransduction; monocyte

Objective. In recent years, continuous intravenous propofol infusion has been widely used in pediatric intensive care units. Several case reports have raised concerns about its safety. The objective of this study was to report our experience with continuous intravenous propofol in consecutive patients during an 18-month period. Methods. The study design was a retrospective review of a case series. Case was defined as a critically ill child who was treated with continuous intravenous propofol. The attending physician staff agreed to prescribe propofol via continuous intravenous infusion at a dose not to exceed 50/ [micro]g/kg/min. The protocol allowed for each patient to receive an additional intravenous bolus of propofol at a dose of 1 mg/kg no more than once per hour. The study entailed data collection from consecutive patients who were prescribed a continuous infusion of propofol in either the pediatric intensive care unit or bone marrow transplant unit. Results. Data from 142 patients were analyzed. Each patient enrolled was adequately sedated. Administration of propofol via continuous intravenous infusion was not associated with metabolic acidosis or hemodynamic compromise. No patient in the study group was inadvertently extubated or had a central venous catheter accidentally discontinued. Conclusions. Propofol can be safely and effectively used to provide sedation to critically ill infants and children. We speculate that continuous infusion of propofol for extended periods of time should not exceed 67 [micro]g/kg/min. Pediatrics 2002;110:1177-1181; sedation, metabolic acidosis, mechanical ventilation., ABBREVIATIONS. PICU, pediatric intensive care unit; BMT, bone marrow transplantation; FDA, US Food and Drug Administration. Providing effective and safe sedation for young children in the pediatric intensive care unit [...]

Byline: A. A. Weinbroum (1), P. Halpern (2), V. Rudick (1), P. Sorkine (1), M. Freedman (1), E. Geller (1) Keywords: Key words Midazolam; Propofol; ICU; Prolonged sedation Abstract: Objective: To compare the efficacy, safety, and cost of midazolam and propofol in prolonged sedation of critically ill patients. Design: Randomized, prospective study. Setting: General intensive care unit Author Affiliation: (1) Departments of Anesthesiology and Critical Care Medicine, Tel-Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Israel, IL (2) Department of Emergency Medicine, Tel-Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, Tel-Aviv 64239, Israel, FAX: + 972 (3) 697 4670, IL Article note: Received: 5 May 1997 Accepted: 18 October 1997

Byline: G. McLeod (1), C. Wallis (1), J. Dick (2), C. Cox (1), A. Patterson (3), J. Colvin (1) Keywords: Key words Propofol; Critical care; Intensive care Abstract: Objective: The assessment of propofol to produce diurnal sedation in critically ill patients Design: Prospective clinical study Setting: Intensive Care Unit, University Hospital Patients and participants: Thirty consecutive patients admitted to the Intensive Care Unit older than 18 years who were expected to be sedated for more than 50 h Interventions: The patients were randomised into two groups. All received sedation with a constant background infusion of morphine and a variable infusion rate of propofol, which was altered hourly to maintain the intended sedation score. The first group received constant light sedation (CLS) over 50 h aiming for a Ramsay score of 2--3. The second group received CLS between 0600 h and 2200 h and additional night sedation (ANS) with propofol between 2200 h and 0600 h, aiming for a sedation score of 4--5. Measurements and results: Patients were studied for 50 h from 1800 h on the first day of admission. Recordings of heart rate, blood pressure, sedation scores and propofol and morphine infusion rates were made hourly. An APACHE II score was recorded for each patient. Sedation scores were analysed by blind visual assessment and cosinor analysis, which is used in chronobiology to examine the correlation of data with a cosine curve. Patients in the ANS group had significantly better rhythmicity of sedation levels using cosinor analysis (r = 26 % v 8 %) p &lt 0.01. There was no difference between the CLS and ANS groups with respect to age, sex or APACHE II scores. Nine out of 15 patients in the ANS group achieved diurnal sedation. Three patients in the CLS group showed diurnal rhythmicity of sedation, which can be attributed to natural sleep, and had a median APACHE II score of 12. Five patients in the CLS group and three in the ANS group showed a deep constant sedation pattern. They had high APACHE II scores (median 21.5) and an obtunded conscious level on admission due to severe sepsis. Conclusion: Propofol can safely provide diurnal sedation in the critically ill when titrated against the Ramsay score. Sedation levels cannot be manipulated in some severely ill patients. Author Affiliation: (1) Department of Intensive Care Medicine, Ninewells Hospital and Dundee Medical School, Dundee DD1 9SY, Scotland FAX: +44 (13 82) 644 914, GB (2) Department of Medicine, Ninewells Hospital and Dundee Medical School, Dundee DDI 9SY, Scotland, GB (3) Department of Physiology, University of St. Andrews, Scotland, GB Article note: Received: 7 August 1996 Accepted: 16 January 1997

Byline: Priyanka. Khurana, Ankit. Agarwal, R. Verma, P. Gupta Regional anaesthesia has become an important anaesthetic technique. Effective sedation is an essential for regional techniques too. This study compares midazolam [...]