Browsing by Subject "Propofol"

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    ItemOpen Access
    Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: dose-response data and safety profile.
    (Anesth Analg, 2010-05-01) Bebawy, John F; Gupta, Dhanesh K; Bendok, Bernard R; Hemmer, Laura B; Zeeni, Carine; Avram, Michael J; Batjer, H Hunt; Koht, Antoun
    BACKGROUND: Adenosine-induced transient flow arrest has been used to facilitate clip ligation of intracranial aneurysms. However, the starting dose that is most likely to produce an adequate duration of profound hypotension remains unclear. We reviewed our experience to determine the dose-response relationship and apparent perioperative safety profile of adenosine in intracranial aneurysm patients. METHODS: This case series describes 24 aneurysm clip ligation procedures performed under an anesthetic consisting of remifentanil, low-dose volatile anesthetic, and propofol in which adenosine was used. The report focuses on the doses administered; duration of systolic blood pressure <60 mm Hg (SBP(<60 mm Hg)); and any cardiovascular, neurologic, or pulmonary complications observed in the perioperative period. RESULTS: A median dose of 0.34 mg/kg ideal body weight (range: 0.29-0.44 mg/kg) resulted in a SBP(<60 mm Hg) for a median of 57 seconds (range: 26-105 seconds). There was a linear relationship between the log-transformed dose of adenosine and the duration of a SBP(<60 mm Hg) (R(2) = 0.38). Two patients developed transient, hemodynamically stable atrial fibrillation, 2 had postoperative troponin levels >0.03 ng/mL without any evidence of cardiac dysfunction, and 3 had postoperative neurologic changes. CONCLUSIONS: For intracranial aneurysms in which temporary occlusion is impractical or difficult, adenosine is capable of providing brief periods of profound systemic hypotension with low perioperative morbidity. On the basis of these data, a dose of 0.3 to 0.4 mg/kg ideal body weight may be the recommended starting dose to achieve approximately 45 seconds of profound systemic hypotension during a remifentanil/low-dose volatile anesthetic with propofol induced burst suppression.
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    ItemOpen Access
    Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study.
    (Spine, 2020-07) Walker, Corey T; Kim, Han Jo; Park, Paul; Lenke, Lawrence G; Weller, Mark A; Smith, Justin S; Nemergut, Edward C; Sciubba, Daniel M; Wang, Michael Y; Shaffrey, Christopher; Deviren, Vedat; Mummaneni, Praveen V; Chang, Joyce M; Mummaneni, Valli P; Than, Khoi D; Berjano, Pedro; Eastlack, Robert K; Mundis, Gregory M; Kanter, Adam S; Okonkwo, David O; Shin, John H; Lewis, Jason M; Koski, Tyler; Hoh, Daniel J; Glassman, Steven D; Vinci, Susan B; Daniels, Alan H; Clavijo, Claudia F; Turner, Jay D; McLawhorn, Marc; Uribe, Juan S

    Study design

    Expert opinion-modified Delphi study.

    Objective

    We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals.

    Summary of background data

    Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice.

    Methods

    We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus."

    Results

    Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals.

    Conclusion

    Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices.

    Level of evidence

    5.
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    ItemOpen Access
    Variation in propofol induction doses administered to surgical patients over age 65.
    (Journal of the American Geriatrics Society, 2021-08) Schonberger, Robert B; Bardia, Amit; Dai, Feng; Michel, George; Yanez, David; Curtis, Jeptha P; Vaughn, Michelle T; Burg, Matthew M; Mathis, Michael; Kheterpal, Sachin; Akhtar, Shamsuddin; Shah, Nirav

    Background/objectives

    Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery.

    Design

    Retrospective observational study using the Multicenter Perioperative Outcomes Group data set.

    Setting

    Thirty-six institutions across the United States.

    Participants

    A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018.

    Intervention

    None.

    Measurements

    Total induction bolus dose of propofol administered.

    Results

    The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older.

    Conclusion

    The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.