Zhang Xiaoyu, Xu Tao, An Xiaohu, Wang Jianwei, Meng Qiong, Xu Zifeng
Department of Anesthesiology, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China.
Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.
Ther Adv Drug Saf. 2024 Nov 4;15:20420986241289204. doi: 10.1177/20420986241289204. eCollection 2024.
Outpatient hysteroscopic surgery requires patients to be anaesthetised and recover quickly, and the drugs used must be safe and effective. Remifentanil is typically co-administered with propofol as total intravenous anaesthesia (TIVA) for hysteroscopy because of its favourable pharmacokinetic and pharmacodynamic properties. However, the optimal dose of remifentanil when co-administered with propofol without neuromuscular blocking agents (NMBAs) has not been established.
In this sequential dose-finding study, the 90% effective dose (ED90) of remifentanil effect-site concentration (Ce) combined with propofol without NMBAs during outpatient hysteroscopy was calculated to minimise the side effects of using higher doses.
This sequential dose-finding study was conducted in August 2022.
Forty patients who underwent outpatient hysteroscopy under TIVA were included in the study. With a biased coin up-and-down design, the initial remifentanil Ce was established at 2 ng/mL, and the subsequent remifentanil dosage was determined based on the reaction of the previous patient. The primary outcome was a remifentanil Ce that resulted in successful TIVA by maintaining a Narcotrend index < 60, surgical pleth index (SPI) < 50, and without patient movement throughout hysteroscopy. Secondary outcomes included rates of hypotension-related symptoms and interventions, drug consumption, post-anaesthesia care unit (PACU)-estimated visual analogue scale (VAS) and Ramsay sedation scores, modified Aldrete scores, and other adverse effects of anaesthesia. The ED90 and 95% confidence intervals (CI) were estimated using isotonic regression methods and bootstrapping.
For TIVA without NMBAs during outpatient hysteroscopy, the ED90 Ce of remifentanil combined with propofol was determined to be 2.75 ng/mL (95% CI, 2.50-3.00 ng/mL). The incidence of peri-operative adverse effects of anaesthesia was relatively low. All the patients had satisfactory VAS, Ramsay sedation, and modified Aldrete scores in the PACU.
Remifentanil at a Ce of 2.75 ng/mL is recommended for TIVA combined with propofol in outpatient hysteroscopic surgery.
http://www.chictr.org.cn (ChiCTR2200062284; 31/7/2022).
门诊宫腔镜手术要求患者麻醉后能快速恢复，所使用的药物必须安全有效。瑞芬太尼因其良好的药代动力学和药效学特性，通常与丙泊酚联合用于宫腔镜手术的全静脉麻醉（TIVA）。然而，在不使用神经肌肉阻滞剂（NMBA）的情况下，瑞芬太尼与丙泊酚联合使用时的最佳剂量尚未确定。
在这项序贯剂量探索研究中，计算门诊宫腔镜手术期间瑞芬太尼效应室浓度（Ce）与丙泊酚联合使用且不使用NMBA时的90%有效剂量（ED90），以尽量减少使用高剂量带来的副作用。
这项序贯剂量探索研究于2022年8月进行。
纳入40例在TIVA下接受门诊宫腔镜手术的患者。采用偏倚硬币上下法设计，初始瑞芬太尼Ce设定为2 ng/mL，随后根据前一位患者的反应确定瑞芬太尼剂量。主要结局是通过在宫腔镜检查全过程中维持脑电双频指数（Narcotrend指数）<60、手术体动指数（SPI）<50且患者无体动，从而实现成功的TIVA的瑞芬太尼Ce。次要结局包括低血压相关症状和干预的发生率、药物消耗量、麻醉后恢复室（PACU）估计的视觉模拟量表（VAS）和 Ramsay 镇静评分、改良 Aldrete 评分以及其他麻醉不良反应。使用等渗回归方法和自抽样法估计ED90和95%置信区间（CI）。
对于门诊宫腔镜手术中不使用NMBA的TIVA，瑞芬太尼与丙泊酚联合使用时的ED90 Ce被确定为2.75 ng/mL（95%CI，2.50 - 3.00 ng/mL）。围手术期麻醉不良反应的发生率相对较低。所有患者在PACU中的VAS、Ramsay镇静和改良Aldrete评分均令人满意。
门诊宫腔镜手术中，推荐瑞芬太尼Ce为2.75 ng/mL与丙泊酚联合用于TIVA。
