Comparison of TCI Remifentanil and manual Remifentanil regimen as part of TIVA for day case gynaecological laparoscopic surgery.

S Chandrashekhar, A A Samaan

Diana Princess of Wales Hospital, Grimsby

Introduction.

Total Intravenous anaesthesia (TIVA) with Propofol and Remifentanil has a number of advantages for day-case gynaecological laparoscopic surgery¹. Remifentanil can be used in either a manual or Target Controlled Infusion (TCI) regimen in TIVA. We compared the dose requirements of Remifentanil using both manual and TCI regimes for day case gynaecological laparoscopic surgery.

Methods.

We had previously conducted an observational study of 83 patients using a manual regimen of Remifentanil and used the data from the afore-mentioned study to calculate the dose requirement of Remifentanil (Group 1). We then studied 83 consecutive ASA I and II patients undergoing gynaecological day-case surgery using a TCI regimen (Group 2).

In Group 1, anaesthesia was induced and maintained with Target Controlled Infusion of Propofol (Target concentration 3-5 mcg ml^-1 Marsh model) and Remifentanil (1 mcg/kg bolus followed by 0.2-0.5 mcg kg ^-1 min^-1 infusion. In Group 2, anaesthesia was induced and maintained with Target Controlled Propofol (Target concentration 3-5 mcg ml^-1) and Target Controlled Remifentanil (Target concentration 3-5 ng ml^-1 Minto model) infusions. In both groups, TCI infusions were delivered with Fresenius TCI system. In patients of both Group1 and Group 2, controlled ventilation with an air/oxygen mixture was maintained using an LMA with tidal volumes of 400 ml, respiratory rate of 12 breaths per minute and I:E ratio of 1:2 without any muscle relaxants. Intra-operatively, all patients received analgesia with intravenous Paracetamol, Ketorolac and Pethidine and a prophylactic anti-emetic (Ondansetron 4 or 8 mg). The total dose of Propofol and Remifentanil used, intra-operative conditions, ease of ventilation, peak airway pressures, mean airway pressures, post-operative recovery characteristics were studied.

Results.

Patients in both groups were comparable in their age and weight. The dose requirements for Remifentanil and Propofol in the two groups are as shown in the table:

The two groups were comparable in their peak and mean airway pressures, ease of ventilation, PONV, side effects and post-operative complications.

 Conclusion

We have demonstrated that TIVA with TCI Propofol and either TCI or manual 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. Further, the use of TCI Remifentanil resulted in a 20% decrease in the amount of Remifentanil used as compared to the manual regimen while producing similar operating conditions and airway pressures.  

Reference

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