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| The UK Society for Intravenous Anaesthesia |
| Based in the UK - as a resource for Anaesthesia Worldwide |
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Evaluation of Propofol and Remifentanil Sedation with Epidural Analgesia for major joint replacement surgery A.A. Samaan and V. Srinivasan Department of Anaesthesia, Diana Princess of Wales Hospital, Grimsby, England Introduction Regional anaesthesia offers many advantages for major joint replacement surgery of the lower limb. These operations are usually lengthy and carried out on elderly patients. There is a need for effective and controllable sedation with fast recovery profile. This obviates the need to administer general anaesthesia in addition to the regional anaesthesia. We undertook to evaluate the efficacy and side effects of combined infusions of Propofol and Remifentanil in this clinical set up. Methods This is an observational study of 123 consecutive patients who required joint replacement surgery; primary hip, primary knee, revision hip, revision knee and bilateral hip replacement. Epidural anaesthesia was performed in 111 patients. In 12 patients, an epidural was not possible so they were excluded from the analysis. The Epidural site was either high lumbar or low thoracic. The Local Anaesthetic used was Bupivacaine 0.5%, warmed to body temperature, with Adrenaline added to achieve the strength of 1:200,000. The motor and the sensory functions were checked to ensure adequate blockade. Patients were sedated during the surgery with a manually controlled Remifentanil infusion (20 mg per ml solution) and a Target Controlled Infusion of Propofol. Results Males: 48 Females: 75 Age (years): mean 71.5 range 29 – 93 SD 11.05 Weight(kgs): mean 75.65 range 46 – 118 SD 15.25 The dose required for sedation is shown in the table below:
Discussion 111 patients had their operations performed under epidural anaesthesia. One patient did not want sedation. 110 patients received the sedation. Desaturation episodes were recorded in 4 patients and snoring in 8 patients. These events were resolved by lowering the infusion rate and manual airway support without the need for a Guedel airway. Itching of the nose was observed in 7 patients. 12 patients were so anxious, that they needed Midazolam in addition to the Remifentanil/Propofol sedation. None of the patients experienced nausea. None of the patients needed conversion to general anaesthesia due to excessive sedation. Conclusion Sedation with Propofol and Remifentanil complemented successful Epidural regional anaesthesia for major joint replacement surgery. It was especially valuable in prolonged surgery such as in the case of revision hip replacements. This avoided the need for general anaesthesia. Sedation with Propofol and Remifentanil is associated with minimal side effects, even in prolonged operations of durations up to 260 minutes, provided there is adherence to a carefully titrated dosage. In our experience the average infusion rate for Propofol was 2.5 mg.kg-1.hr-1 and 0.02 mg.kg-1 .min-1 for Remifentanil. |
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