Mustafa ULU, Tülin GÜMÜŞ, Ezgi ERKILIÇ, Orhan KANBAK

Fonksiyonel endoskopik sinüs cerrahisinde hedef kontrollü infüzyonda farklı remifentanil düzeylerinin peroperatif etkileri

Amaç: Bu çalışmada, hedef kontrollü infüzyon (HKI) yöntemi ile propofol ve iki farklı dozda remifentanilin fonksiyonel endoskopik sinüs cerrahisinde intraoperatif kontrollü hipotansiyon oluşturulması, cerrahi sahada kanama üzerine olan etkileri ve postoperatif derlenme dönemi üzerine olan etkilerinin değerlendirilmesi amaçlandı. Gereç ve Yöntem: Çalışmaya hastane etik kurul izni ve bilgilendirilmiş hasta onamları alındıktan sonra ASA I-II grubu, fonksiyonel endoskopik sinüs cerrahisi uygulanacak 18-65 yaşları arasındaki 60 hasta dahil edildi. Bazal hemodinamikparametreler kaydedildikten sonra daha önceden Ailen testi yapılmış ve lokal anestezik uygulanmış koldan radial arter kanülasyonu uygulandı. Anestezi indüksiyonu 2 mg kg' propofol ve 1 pıg kg' remifentanil ile yapıldı. Anestezi idamesinde Orchestra base primea (Fresenius-Vial) hedef kontrol infüzyon cihazı kullanılarak propofol ve remifentanil infüzyon dozları (Propofol idamesi plazma konsantrasyonu 4 pıg mi'1 , Remifentanil idamesi rastgele ayrılan Grup R3'e 3 ng ml "' ve Grup R6'ya ise 6 ng mi') Marsh ve Minto farmokinetik modellerine göre ayarlandı. Hedeflenen Ortalama arter basıncı (OAB) olan 60-70 mmHg değerine ulaştığında cerrahiye izin verildi. Peroperatif dönemde OAB'nin hedeflenen değerin 5 dk.'dan uzun süre yüksek devam etmesi durumunda nitrogliserin infüzyonu uygulandı. O AB hedeflenen basınca düştüğünde kapatılıp kullanılan ilaç miktarı not edildi. Operasyon bitiminde Aldrete skorlaması kullanılarak uyanma süreleri kaydedildi. Bulgular: Hedeflenen O AB değerine R3 grubunda 5,98 ± 4,97 dk.'da, R6 grubunda ise 3,69 ± 2,24 dk.'da ulaşıldı. Çalışmamızda cerrahi başladıktan sonraki 15. ve 20. dk.'lardaki OAB değerlerinin Grup R6'da, Grup R3'e göre daha düşük olduğu saptandı. Her iki grup arasında, Kalp atım hızı (KAH) açısından değerlendirildiğinde cerrahi başlangıcını izleyen 20. dk. ve diğer tüm zamanlarda Grup R6'da Grup R3'e göre belirgin olarak azalma saptandı. Grup R3'de ekstübasyon zamanı 10,09 ± 2,78 dk. ve Grup R6'da ise 13,21 ±. 3,78 dk. olarak bulundu. Nitrogliserin gereksinimi Grup R3'de % 40, Grup R6'da % 13,3 olarak saptandı. Sonuç: Propofol ile-remifentanil uygulamasının cerrah için yeterli kansız saha sağlaması, derlenmenin kısa olması nedeniyle endoskopik sinüs cerrahisinde kontrollü hipotansiyon için uygun bir seçenek olduğu kanısına varıldı. Ayrıca ek hipotansif ajan gereksiniminin daha az olması nedeniyle HKI yönteminde remifentanilin 6 ng ml'1 plazma konsantrasyonunda uygulanmasının seçilebileceği düşüncesindeyiz.

Peroperative effects of different remifentail levels in target controlled infusion in functıonal endoscopic sınus surgery

Objective: In this study, we aimed to evaluate the peroperative effects of propofol and two different doses of remifentanil using target controlled infusion technique (TCI) on controlled hypotension, bleeding in the surgical field and recovery in functional endoscopic sinus surgery. Material and Method: After instutional ethics commitee approval and a written statement of informed consent obtained from each patient, 60 patients of American Society of Anesthesiology physical status I-II, aged 18-65 years, who were scheduled for elective functional endoscopic sinus surgery were involved in the study. Following record of the basal hemodynamic parameters, radial arterial canulation was performed with local anesthetic application, on the arm that was controlled by Allen test. Anesthesia was induced by 2 mg kg' propofol and 1 jig kg' remifentanil. Orchestra baseprimea (Fresenius-Vial) target controlled infusion device was used with propofol and remifentanil for maintanence of anesthesia. The patients were enrolled into two groups with regard to their remifentanil infusion rates according to the Marsh and Minto farmocokinetic models, which are named as R3 and R6 randomly. Propofol was given to all patients in both groups in a plasma concentration of 4 jig ml'1 and Groups R3 and R6 were administered remifentanil in plasma concentrations of 3 or 6 ng ml'1, respectively. Surgery was started when the target mean arterial blood pressure (MAP) which was 60-70 ritmHg, was reached. Nitroglycerine was infused when MAP was higher than target values for more than 5 min and discontinued if the target MAP was reached. Then the consumed drug was recorded. Extubation times were also recorded at the end of surgery by using Aldrete scoring. Results: Target MAP was reached in 5.98 ± 4.97 min and 3.69 ± 2.24 min in Group R3 and Group R6, respectively. In our study, it was determined that MAP values of Group R6 were lower than those of Group R3 at the 15 f and 20"' minutes of the surgery. Heart rates were significantly lower at R6 in comparison to R3 group at the 20"' min of the surgery and afterwards. Extubation times were recorded as 10.09 ± 2.78 min and 13.21 ± 3.78 min in R3 andR6 groups, respectively. The requirement of nitroglycerin was 40 % in Group R3 and 13.3 % in Group R6. Conclusion: It is concluded that controlled hypotension provided by propofol and remifentanil, using TCI, might be an appropriate choice for providing a bloodless surgical field for the surgeon and reducing extubation time in functional endoscopic sinus surgery. However, we suggest that controlled hypotension with remifentanil used in a plasma concentration of 6 ng ml'1 may be a better choice because of providing reduced needs of hypotensive agents.

PDF

___

1.Stammberger H. Results, problems and complications. In: Stammberger H, ed. Functional endoscopic sinus surgery. The Messerklinger technique. Philadelphia; B.C. Decker 1991; 459-77.
2.Kerr AR. Anaesthesia with profound hypotension for middle ear surgery. Br J Anaesth. 1977 May;49(5):447-52.
3.Degoute CS. Controlled hypotension: a guide to drug choice. Drugs. 2007;67(7): 1053-76.
4.Kayhan Z. Klinik Anestezi Genişletilmiş 3. Baskı. Ankara: Logos Yayıncılık; 2004, Bölüm XIX-80: 496-501.
5.Morgan GE, Mikhail MS, Murray MJ. Hypotensive Agents. In: Clinical Anesthesiology 3rd edition. California, McGraw-Hill 2002,231-2.
6.Marchal JM, Gomez-Luque A, Martos-Crespo F, Sanchez De La Cuesta F, Martinez-Lopez MC, Delgado-Martinez AD. Clonidine decreases intraoperative bleeding in middle ear microsurgery. Acta Anaesthesiol Scand. 2001 May;45(5):627-33.
7.Piper SN, Suttner SW, Maleck WH, Kümle B, Haisch G, Boldt J. Effects of sodium nitroprusside-induced controlled hypotension on pancreatic function assessed by pancreatitis-associated protein in patients undergoing radical prostatectomy. Eur J Anaesthesiol.2002Aug;19(8):609-13.
8.Glass PS, Shafer SL, Reves JG. Intravenous drug delivery systems. In: Miller's Anesthesia 5th edition. New-York, Churchil Livingstone 2000, 377-411.
9.van den Nieuwenhuyzen MC, Engbers FH, Vuyk J, Burm AG. Target-controlled infusion systems: role in anaesthesia and analgesia. Clin Pharmacokinet. 2000 Feb;38(2):181-90.
10.Marsh B, White M, Morton N, Kenny GN. Pharmacokinetic model driven infusion of propofol in children. Br J Anaesth. 1991 Jul;67(l):41-8.
11.Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanil. II. Model application. Anesthesiology. 1997 Jan;86(l):24-33.
12.Ragab SM, Hassanin MZ. Optimizing the surgical field in pediatric functional endoscopic sinus surgery: a new evidence-based approach. Otolaryngol Head Neck Surg. 2010 Jan;142(l):48-54.
13.Eberhart LH, Folz BJ, Wulf H, Geldner G. Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery. Laryngoscope. 2003 Aug;113(8):1369-73.
14.Degoute CS, Ray MJ, Gueugniaud PY, Dubreuil C. Remifentanil induces consistent and sustained controlled hypotension in children during middle ear surgery. Can J Anaesth. 2003 Mar;50(3):270-6.
15.Manola M, De Luca E, Moscillo L, Mastella A. Using remifentanil and sufentanil in functional endoscopic sinus surgery to improve surgical conditions. ORL J Otorhinolaryngol Relat Spec. 2005; 67(2):83-6.
16.Wormald PJ, van Renen G, Perks J, Jones JA, Langton-Hewer CD. The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery. Am J Rhinol. 2005 Sep-Oct;19(5):514-20.
17.Baker AR, Baker AB. Anaesthesia for endoscopic sinus surgery. Acta Anaesthesiol Scand. 2010 Aug;54(7):795-803.
18.Ausems ME, Vuyk J, Hug CC Jr, Stanski DR. Comparison of a computer-assisted infusion versus intermittent bolus administration of alfentanil as a supplement to nitrous oxide for lower abdominal surgery. Anesthesiology. 1988 Jun;68(6):851-61.
19.Passot S, Servin F, Allary R et al. Target-controlled versus manually-controlled infusion of propofol for direct laryngoscopy and bronchoscopy. Anesth Analg. 2002 May;94(5): 1212-6
20.De Castro V, Godet G, Mencia G, Raux M, Coriat P. Target-controlled infusion for remifentanil in vascular patients improves hemodynamics and decreases remifentanil requirement. Anesth Analg. 2003 Jan;96(l):33-8
21.Liu SH, Wei W, Ding GN, Ke JD, Hong FX, Tian M. Relationship between depth of anesthesia and effect-site concentration of propofol during induction with the target-controlled infusion technique in elderly patients. Chin Med J (Engl). 2009 Apr 20;122(8):935-40.
22.Guignard B, Menigaux C, Dupont X, Fletcher D, Chauvin M. The effect of remifentanil on the bispectral index change and hemodynamic responses after orotracheal intubation. Anesth Analg. 2000 Jan;90(l): 161-7.
23.Degoute CS, Ray MJ, Manchon M, Dubreuil C, Banssillon V. Remifentanil and controlled hypotension; comparison with nitroprusside or esmolol during tympanoplasty. Can J Anaesth. 2001 Jan;48(l):20-7.
24.Hancı A, Karahan T, Sivrikaya GU, Başgül A, Coşkun BU. Timpanoplasti olgularında kontrollü hipotansiyon: Remifentanil ve alfentanil-sodyum nitroprusid kombinasyonunun karşılaştırılması. Kulak Burun Boğaz Ihtis Derg 2007; 17: 311-7.
25.Dal D, Celiker V, Özer E, Başgül E, Salman MA, Aypar U. Induced hypotension for tympanoplasty: a comparison of desflurane, isoflurane and sevoflurane. Eur J Anaesthesiol. 2004 Nov;21(ll): 902-6.
26.Philip BK, Scuderi PE, Chung F et al. Remifentanil compared with alfentanil for ambulatory surgery using total intravenous anesthesia. The Remifentanil/Alfentanil Outpatient TIVA Group. Anesth Analg. 1997 Mar;84(3):515-21.