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Propofol-Remifentanil Combinations for TIVA in Children

Oliver Bagshaw, Department of Anaesthesia, Birmingham Children’s Hospital

Introduction

The technique of total intravenous anaesthesia (TIVA) is well established in adult practice, particularly since the advent of target controlled infusion (TCI). Until the development of the Paedfusor™, modern TCI pumps were not suitable for children under the weight of 30kg, consequently the author has been limited to practicing a modified Bristol regime in most patients[1]. Since the introduction of remifentanil into clinical practice at Birmingham Children’s Hospital in 1998, it has become the opioid of choice to supplement TIVA. This report is a summary of the author’s experience using propofol-remifentanil combinations for TIVA in children.

Patients and Methods

Between 2000 and 2004, the author collected data on a total of 90 ASA 1 and 2 paediatric patients anaesthetised with TIVA for a variety of elective surgical procedures. Anaesthesia was induced by propofol bolus, or by inhalation induction with sevoflurane. If patients underwent inhalational induction, they generally received a bolus of propofol prior to the initiation of TIVA (2-5 mg.kg^-1). All patients received a modified Bristol regime with the administration of propofol by continuous infusion. The initial propofol infusion rate was set at between 9 and 12 mg.kg^-1.hr^-1, depending on the age of the child, and reduced every 10 minutes to the lowest clinically acceptable rate. Remifentanil was started either slightly before the propofol (IV induction) or at the same time (inhalational induction), at a rate generally between 0.5 and 1 mg.kg^-1.min^-1. This was reduced to a maintenance level of 0.25 mg.kg^-1.min^-1, unless clinical factors dictated otherwise. Both infusions were either continued until the end of surgery, or stopped a few minutes before surgery was completed. No patient received nitrous oxide for maintenance of anaesthesia. Additional analgesia was provided by local anaesthetic techniques and combinations of other analgesics. The author noted any complications that occurred during the peri-operative period that he suspected to be related to the TIVA technique.

Results

The patients had a mean age and weight of 62.1 months (range 3-184) and 20.0kg (range 4.6-71) respectively. Most patients underwent either cleft lip or cleft palate repair (41%). The remaining operations were a mixture of plastic, paediatric surgical, orthopaedic, ENT and ophthalmology procedures. Inhalational induction of anaesthesia was used in 29 patients and 53 underwent endo-tracheal intubation. The remainder were managed with an LMA. All patients received IPPV during anaesthesia. Muscle relaxation with rocuronium was used in 84% of patients. The Tables show the infusion data for both propofol and remifentanil:

 Propofol (mg.kg^-1.hr^-1)

 Remifentanil (µg.kg^-1.min^-1)

Patients under 36 months age received significantly more propofol, but not remifentanil, than those over 36 months age (p<0.0001). There were a total of 30 complications recorded in 29 patients. By far the commonest was bradycardia, which was seen in 17 patients, although this was rarely associated with hypotension and didn’t generally require intervention. The postoperative recovery of the patients was generally very good. There were no cases of laryngospasm or episodes of vomiting noted during the recovery period. 

Discussion

TIVA using propofol and remifentanil appears to be a safe and effective technique for all ages of children undergoing a variety of surgical procedures. The quality of anaesthesia and recovery is good and the only common complication appears to be bradycardia, which occurs in about 20% of patients.

Reference

Browne BL, Prys-Roberts C, Wolf AR. Propofol and alfentanil in children: infusion technique and dose requirement for total i.v.anaesthesia. Br J Anaesth. 1992 Dec; 69:570-6