Observational study on TIVA with TCI Propofol and TCI Remifentanil for day case gynaecological laparoscopic surgery without muscle relaxants

S Chandrashekhar,  A A Samaan, Diana Princess of Wales Hospital, Grimsby

Introduction:

Total Intravenous anaesthesia (TIVA) has a number of advantages for day-case gynaecological laparoscopic surgery¹. We evaluated an anaesthetic technique of TIVA using Target Controlled Infusions (TCI) of Propofol and Remifentanil and controlled ventilation without muscle relaxants in patients undergoing day-case gynaecological laparoscopic surgery.

Methods.

100 consecutive patients (ASA I or II) undergoing day-case gynaecological laparoscopic surgery were included in this prospective study. Anaesthesia was induced and maintained with Target Controlled Propofol (Target concentration 3-5 mcg ml^-1 Marsh model) and Target Controlled Remifentanil (Target concentration 3-5 ng ml^-1 Minto model) infusions delivered via Fresenius TCI system. Controlled ventilation with an air/oxygen mixture was maintained using an LMA without any muscle relaxants. Intra-operatively, all patients received analgesia in the form of intravenous Paracetamol, Ketorolac and Pethidine. All patients received prophylactic anti-emetic (Ondansetron 4 or 8 mg) intra-operatively. The total dose of Propofol and Remifentanil used, intra-operative conditions, ease of ventilation, peak airway pressures, mean airway pressures, post-operative recovery characteristics and post-operative complications (PONV, pain, delay in discharge time) were studied.

Results.

The mean age and weight (± SD) of the patients was 33.62 ± 7.1 years and 69.39 ± 14.04 kgs respectively. The duration of anaesthesia was 34.76 ± 9.80 minutes. For analysis, patients were also divided into 2 groups (TCI Plasma n=48 and TCI Effect Site n=52). The table below shows the dose requirement of Propofol and Remifentanil. Values are shown as mean, standard deviation and range. 

All 100 patients were successfully ventilated with LMA without muscle relaxants. 8% of patients needed ventilation change to I: E = 1:1 The peak airway pressure recorded (mean ± SD) was 22.08 ± 4.13 cms of water. Side effects recorded were bradycardia (1%), hypotension (6%), PONV (4%). 11% patients required additional post-operative analgesia before discharge.

Conclusion

We have demonstrated that TIVA with TCI Propofol and TCI Remifentanil is a safe and effective technique for day-case gynaecological laparoscopic surgery and controlled ventilation can be effectively provided in this setting without muscle relaxants.

References

1.        Juckenhofel S Feisel C Schmitt HJ Biedler A. TIVA with propofol-remifentanil or balanced anaesthesia with sevoflurane-fentanyl in laparoscopic operations. Haemodynamics, awakening and adverse effects.Anaesthetist 48 (11):807-12, 1999 Nov