Minerva anestesiologica
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Minerva anestesiologica · May 2000
ReviewWhy should I change my practice of anaesthesia: neuromuscular blocking agents.
Recently, four neuromuscular blocking agents have been introduced into clinical practice. The drug companies claim that these new drugs offer several important advantages. But is this true? Do the new neuromuscular blocking agents add anything to our clinical practice, and will their introduction really benefit our patients? Or will it only benefit the economy of the companies? ⋯ In this lecture I shall try to update you on these new drugs and give you my personal bias on when to use the different (new and old) neuromuscular blocking agents.
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Sevoflurane and Desflurane are relatively new halogenated agents which make induction and control of depth of anaesthesia easier, recovery rapid and of good quality and they have less side-effects and toxicity. In children sevoflurane could replace halothane because it provides smooth and rapid induction with less cardiovascular depression and arrhythmias. Desflurane is not used because of its pungent odour. In adults sevoflurane could be preferred to desflurane because it allows rapid induction and laryngeal mask insertion or tracheal intubation without myorelaxants, a similar time of recovery, no clinical evidence for renal and hepatic toxicity, no more costs for anaesthesia for a lower MAC.
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Minerva anestesiologica · May 2000
Review[Bispectral index: clinical effectiveness and role in reducing anesthetic drug consumption].
A numeric value derived from bispectral analysis of EEG, the bispectral index (BIS), has been recently introduced as a monitor of the hypnotic component of anaesthesia. Application of BIS monitoring in anaesthesia appears extremely interesting to drugs titration and drugs economy, and in the evaluation of time for discharge in a one day surgery regimen. In this prospective study ASA I-II patients for Day-Surgery were enrolled in three groups: subaracnoid anaesthesia (SA), general anaesthesia (GA) with BIS and GA without BIS monitoring. ⋯ No significant differences were measured between the GA groups. A longer time of recovery was necessary in the SA group. A greater amount of anaesthetic in BIS group could be attributed to a better monitoring of sedation which prevents intraoperative awakening.
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The selection of opioid drugs for anesthesia is often based on empirical judgment such as the selection of opioids with rapid elimination half-life for short surgical procedures (e.g. alfentanil), while opioids with longer elimination half-life (e.g. fentanyl, sufentanil) are used for longer procedures. A better insight in the pharmacokinetic and pharmacodynamic differences between opioids allows a more rational selection of the drug and its dosing scheme, and will contribute to rapid recovery after anesthesia. As opioids are adjuncts to other anesthetic drugs, drug interaction principles should be considered when titrating the opioid administration.
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Drug development in anaesthesia poses specific challenges. Describing the development of remifentanil highlights some of these. A new drug in anaesthesia must achieve its clinical goals in all patients and significant levels of toxicity are unacceptable. ⋯ The insertion of an alkyl ester group into this 4-anilidopiperidine molecule has resulted in a compound which, whilst retaining the desired mu-opioid receptor pharmacology, is susceptible to metabolism by non-specific esterases in the blood and tissues. The rapid onset and offset of action means that the anaesthetist can deliver high doses of opioid resulting in stable anaesthesia and the lack of accumulation ensures that even after prolonged infusion remifentanil does not compromise recovery. This ability to control the anaesthetic process has relevance in both short and long procedures and the unique characteristics of remifentanil may also in the future prove to have utility in the intensive care setting.