1. 경희의료원 마취통증의학과 R3 전주연 British journal of anaesthesia. 2005;94:778-83
Comparison of propofol/remifentanil and sevoflurane/remifentanil for maintenance of anaesthesia for elective intracranial surgery
경희의료원
마취통증의학과
R3 전주연
British journal of anaesthesia. 2005;94:778-83

2. Background
IV and inhalation agents are in general use for maintenance of anesthesia during neurosurgery
Comparisons btw iv and inhalation have been inconclusive
Remifentanyl – rapid onset, promptly elimination, low instance of pain
No published reports, compare sevo/remi and propofol/remi in neurosurgery

3. Methods Fifty pts. Undergoing elective craniotomy
Double-blind design- rejected (easy detection of sevoflurane by smell)
Arterial pressure- direct measurement from the radial a. and stored at 1-min intervals
Hypertension and hypotension by inspection of the stored electronic record

4. Method-Anaesthesia Remifentanyl Group P (propofol anesthesia)
Bolus- 1μg/kg
Infusion- 0.5 μg/kg – 0.25 μg/kg after craniotomy
Group P (propofol anesthesia)
TCI (Target controlled infusion) of propofol
Initial plasma conc. – (1 μg/ml) was increased progressively until satisfactory anesthesia
Maintained by the TCI with a minimum target conc. Of 2 μg/ml

5. Method-Anaesthesia Group S (sevoflurane anesthesia)
Bolus injection propofol- 0.5mg/kg c supplementary doses of 10mg every 10s until loss of consciousness
Maintain
Initial ET conc. 2% minimum conc. 1%
Tracheal intubation
Atracurium as bolus and followed by an infusion until dural closure
Normocapnia
Fresh gas flow – 0.5L/min O2, 1.0L/min Air

6. Method-Anaesthesia Remifentanyl infusion stopped after skin closure
Sevoflurane and propofol were continued until head bandaging was completed
Mannitol
1g/kg – given bt induction of anesth. And craniotomy
Surgeon – state of brain(tight, adequate, soft)
Dose of mannitol was recorded

7. Method-Anaesthesia Hypertensive episode Hypotensive episode
MAP > 100mmHg for more than 1min
Treated c remi 1 μg/kg and infusion rate increased by μg/kg/min
Labetolol or hydralazine was given
Hypotensive episode
MAP < 60mmHg for more than 1min
Reducing the propofol target or sevoflurane conc.
Vasopressor was administered if necessary

8. Method-Anaesthesia
Time to adequate respiration, extubation, eye opening and obey commands
Analgesia was provided by bolus injections of morphine 2mg
Nausea and vomiting and the discharge time were recorded.

9. Method-Statistical analysis
Statview and excel v. 7
Continuous variables
Mann-Whitney U-test
Categorical valuables
chi-squared test
P < 0.05 – statistically significant
Drug acquisition costs
post-hoc

10. Results Group P (24pt.) Group S (26pt.) Remifentanil infusion rate
Propofol infusion rate
5.45 mg/kg/h
Group S (26pt.)
1.06mg/kg propofol for induction
ET conc. Of sevo.
1.13 %
Remifentanil infusion rate
Similar in the two group
Aaesthesia time
Longer in group P – difference was not significant

11. Results Hypertensive episodes Hypotensive episodes
Arterial pressure before, during, and after surgery was similar.
Hypertensive episodes
7 and 8 pt. in group P and S
No significant difference (P=0.374, chi square)
Labetolol 14 and 19pt in group P and S
Hydralazine 2 and 5 pt in group P and S
Hypotensive episodes
15 and 23 pt in group P and S
No significant difference
Ephedrine 63 and 88% pt in group P and S
Total dose of ephedrine 4.8 and 9.8 mg in group P and S

12. Results Time to spontaneous respiration
Shorter in group P and S(P=0.02)
Time to eye opening, extubation, obeying commands
were not statistically significant
Relationship btw. Recovery time and hypotensice episodes
Were not significantly correlated
Requirement for morphine, dosage of morphine, incidences of N/V and recovery room stay were similar

13. Results
Total hypnotic , analgesic drug and vasoactive drug acquisition costs
Group P > Group S (19.31 > 15.52/h)
Significantly high ( P= 0.016)

14. Discussion Sevoflurane and propofol in combination with remifentanil
Satisfactory agents for maintenance of anaesthesia in neurosurgical patients.
Increased number of hypotensive episodes in group S
Group S simply more deeply anaesthetized
CP50 of propofol – 5.45μg/ml
IC50 of sevo – 1.14%
Average target propofol conc. – 3.67 μg/ml
Average ET sevo conc. – 1.13%

15. Discussion
Small and clinically unimportant differences in recovery bt Group P and Group S
Many reports to compare recovery characteristics
Sevoflurane gave faster, similar, or slower recovery than propofol anesthesia
Ex) Yli-Hankala – no difference of recovery
Evaluation whether hypotensive episodes were associated with delayed recovery – No correlation

16. Discussion PONV Small difference in drug acquisition costs
Many studies – sevoflurane caused PONV more frequently than propofol anesthesia.
PONV – 30% of patients receiving sevoflurane
PONV occurred in only 15% of patients with no difference between propofol and sevoflurane
Small difference in drug acquisition costs
Difference are very small in relation to the total cost of a neurosurgical procedure

17. Discussion Both agents were satisfactory
Realistic doses of propofol and sevoflurane
Recognize the strong synergism bt. these agents and remifentanil.
Common clinical doses of remifentanil
Substantial sparing of sevoflurane and propofol
Previous study – propofol infusion rate 100μg/kg/min – too high
We have carefully evaluated sevo, and propofol as maintenance agents with remifentanil for elective intracranial surgery.
Both agents were satisfactory