2005 Annual Scientific Meeting - CLICK FOR PROGRAMME

Total Intravenous Anaesthesia for Total Abdominal Hysterectomy without Muscle Relaxants

 A.A.Samaan, V. Srinivasan

Department of Anaesthesia, Diana Princess of Wales Hospital, Grimsby, England

Introduction

General anaesthesia with muscle relaxants is the standard technique for Total Abdominal hysterectomy (TAH).  TIVA with Remifentanil and Propofol is an alternative technique that either utilises minimal dose of muscle relaxants or none. Remifentanil can produce profound muscle relaxation without blocking the neuro-muscular junction. We undertook this study in order to evaluate the technique for lower abdominal surgery. There is very little literature available on the use of TIVA without muscle relaxants for TAH.

Methods

This was a prospective observational study of 44 consecutive patients who required general anaesthesia for total abdominal hysterectomy.  The surgical access was through a transverse lower abdominal incision. Most of the patients were either ASA I or ASA II.  General anaesthesia was induced with Propofol (TCI to Cp 4 mg.ml^-1 followed by a target of Cp 3-4 mg.ml^-1 for maintenance) and Remifentanil (Loading dose of 1 mg.kg^-1 followed by an infusion of 0.2 – 0.4 mg.kg^-1.min^-1). The lungs were ventilated with oxygen and air through an LMA.  Operative conditions, haemodynamic stability and the need for use of muscle relaxants were recorded. If the surgeon felt the need for muscle relaxation, Atracurium was given in the dose of 10 to 25 mgs.  Peripheral nerve stimulation to the Ulnar nerve was used to assess the muscle relaxation and the need for reversal.

Results

Discussion

16 out of 44 patients (36%) required muscle relaxants.  An average dose of 15 mg of Atracurium was used. 12 out of these 16 patients weighed more than 70 Kgs. None of the patients required a second dose of muscle relaxant.  The surgical conditions were assessed as good or excellent.

There was a noticeable inter-individual variation in the dose of Remifentanil and Propofol needed as shown in the table. Also, this technique was noted to require an above average dose of both Remifentanil and Propofol. The decreased use of Muscle relaxants could be attributed to the use of Remifentanil. Only 1 patient needed reversal of the residual muscle relaxation.

Conclusion

Our experience in the above study has shown that, with Remifentanil and Propofol TIVA, total abdominal hysterectomy can be done without muscle relaxants. This was achieved in 64% of the patients. 36% of patients required only a small dose of muscle relaxant. This reduces the side effects of the relaxants and the requirement for reversal and should lead to a reduction in the incidence of PONV.

References

1.       Hogue CW Jr. et al Multicenter evaluation of total intravenous anaesthesia with remifentanil and propofol for elective inpatient surgery. Anaesthesia & Analgesia 1996; 83: 279-8