Perbedaan Pengaruh Sevofluran dan Propofol Terhadap Kadar IL-6 dan Jumlah Neutrofil pada Operasi Kraniotomi

Latar Belakang: Imunitas bawaan adalah lini pertahanan pertama dan mengacu pada mekanisme perlindungan yang ada bahkan sebelum adanya luka / infeksi. Komponen yang dapat digunakan untuk mengetahui perubahan imunitas antara lain sitokin (IL-6) dan neutrofil. Anestesi umum dapat diberikan dengan menggunakan anestesi inhalasi, obat intravena, atau sebagian besar sering kombinasi keduanya. Semua bentuk obat anestesi ini dapat mempengaruhi sistem kekebalan tubuh dan memberikan efek pada imunitas bawaan.Tujuan: Penelitian ini bertujuan untuk mengetahui perbedaan pengaruh sevofluran dan propofol terhadap sistem imun dinilai dari kadar IL-6 dan neutrofil pada operasi bedah saraf.Metode: Dilakukan penelitian eksperimental terhadap 34 subjek (17 subjek kelompok sevofluran dan 17 subjek kelompok propofol) yang menjalani operasi kraniotomi yang memenuhi kriteria penelitian. Kelompok I (17 subjek) menggunakan sevofluran 1 minimum alveolar concentration (MAC) dan kelompok II (17 subjek) menggunakan propofol maintenance infusion 100 μg/kg/menit. Dilakukan pengambilan sampel darah untuk pemeriksaan kadar IL-6 dan neutrofil saat sebelum operasi dan 2 jam setelah insisi operasi. Data dianalisa secara statistik menggunakan Wilcoxon dan Mann-Whitney test, dianggap bermakna bila p < 0,05.Hasil: Pada penelitian ini didapatkan penurunan kadar neutrofil pada kelompok sevofluran sebesar 0,02 ± 7,54 % dibanding kadar awal (berbeda tidak bermakna p= 0,205) sedangkan pada kelompok propofol didapatkan peningkatan kadar neutrofil sebesar 5,07 ± 7,01% dibanding kadar awal (berbeda bermakna p=0,002). Pada perbandingan selisih kedua kelompok didapatkan perbedaan kadar neutrofil yang bermakna (p=0,003). Kadar IL-6 pada kelompok sevofluran didapatkan peningkatan sebesar 4,86 ± 6,87 pg/ml dibanding kadar awal (berbeda bermakna p=0,017) dan pada kelompok propofol juga didapatkan peningkatan sebesar 15,87 ± 16,12 pg/ml dibanding kadar awal (berbeda bermakna p=<0,001). Pada perbandingan selisih kedua kelompok didapatkan perbedaan kadar IL-6 yang bermakna (p=0,009).Kesimpulan: Sevofluran lebih menurunkan kadar IL-6 dan jumlah neutrofil dibandingkan dengan propofol pada operasi kraniotomi.

Evaluation of Rocuronium Continuous Infusion in Critically Ill Patients During the COVID-19 Pandemic and Drug Shortages

Background: Limited data exist to support the use of rocuronium continuous infusions in the intensive care unit (ICU). Objective: To evaluate the dosing and monitoring of adult patients who received rocuronium for hypoxemic respiratory failure during the Coronavirus Disease 2019 (COVID-19) pandemic. Methods: This was a retrospective, single-center study from March 1, 2020 to May 31, 2020. We identified all adult patients admitted to any ICU who received rocuronium via continuous infusion. Patients were excluded if they received rocuronium for <6 hours. The main outcome of this study was to determine the median rocuronium maintenance continuous infusion rate in the ICU. Secondary outcomes of this study included the initial continuous infusion rate, duration of therapy, cumulative dose, frequency and median of rocuronium boluses, time to resolution of neuromuscular blockade, and the relationship between the hourly administration rates of rocuronium and train-of-four (TOF) assessments. Results: Seventy-one patients and 97 paralytic infusions were included. Fifty-nine patients (83%) were positive for SARS CoV-2. Of the 97 rocuronium infusions, the median dose at initiation was 3 (3–5) mcg/kg/min and duration of infusion was 45 (23.6–92.5) hours. The median continuous infusion maintenance rate was 4.3 (2.8–7.2) mcg/kg/min. There was a negligible correlation between the dose of rocuronium and the TOF results (r = .04). A total of 1775 TOFs were assessed, of which 46.2% were over-paralyzed, 35.7% well-paralyzed, and 18.1% under-paralyzed. Conclusions: The initial and maintenance infusion doses in our analysis were lower than what have been previously referenced.

Comparative study of desflurane requirement and recovery characteristics in entropy guided general anaesthesia with or without dexmedetomidine infusion

Background: Newer anaesthetics such as desflurane have smaller blood-gas partition coefficient than older ones like halothane. Desflurane is preferred because it leads to faster onset of anaesthesia and faster emergence from anaesthesia. However, desflurane is considered to be more expensive than other volatile anaesthetics. Highly selective alpha two adrenoceptor agonists like Dexmedetomidine reduce anaesthetic requirements. Hence this study was designed to compare the effect of Dexmedetomidine infusion on desflurane consumption and recovery characteristics under entropy guided general anaesthesia. Materials and Methods: Fifty patients aged between 18-55 years belonging to ASA I and II scheduled for elective surgeries under general anaesthesia were randomly divided into two groups. Group D patients received a loading dose of inj Dexmedetomidine 1 µg/ kg, over 10 minutes before the induction of anaesthesia, and 0.5 µg/ kg/ hour infusion following induction of anaesthesia till the end of surgery. Group P patients received similar volumes of normal saline as bolus before the induction and maintenance infusion till the end of the surgery. Desflurane concentration was adjusted to maintain response entropy values between 40 to 60 and based on clinical variables like heart rate (HR), and mean arterial pressure (MAP). Muscle relaxation was guided by TOF count. HR, NIBP, MAP, SPO2, ENTROPY values were recorded. The total desflurane consumption was recorded from Anaesthesia gas module of GE Datex-Ohmeda S 5 Advance system. At end of surgery, desflurane was discontinued and patient extubated after adequate recovery and when TOF ratio was more than 0.9. Time to eye opening, extubation, response to verbal commands were recorded. Results: The mean consumption of desflurane at the end of one hour was significantly less in group D with p<0.001 (Group P 21.04±6.33 ml/hr and Group D 14.44±1.83 ml/hr). Eye opening time was significantly less in group D with p<0.001(Group P 297.60± 89.97sec and Group D 169.80±22.48 sec). Time for response to verbal commands was significantly less in group D with p<0.001 (Group P 423.60±113.02 sec and Group D 269.80±45.29 sec) Conclusion: Intraoperative Dexmedetomidine infusion reduces desflurane consumption, hastens recovery from desflurane during entropy guided general anaesthesia.

Prophylactic administration of tirofiban for preventing thromboembolic events in flow diversion treatment of intracranial aneurysms

BackgroundFlow diverter (FD) is widely used in the treatment of intracranial aneurysms. However, thromboembolic events (TEs) continue to be the major complications during the periprocedural phase. To evaluate the safety and efficacy of the prophylactic use of tirofiban, combined with the conventional dual antiplatelet therapy (DAT), as a new antiplatelet protocol in patients with intracranial aneurysms treated with FDs.MethodsAt least 3–5 days before the procedure, daily DAT were administrated to the patients. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period during or immediately after FD deployment, followed by a 0.05 µg/kg/min maintenance infusion for 24–48 hours. Periprocedural TEs and hemorrhagic events (HEs) were recorded.ResultsA total of 331 patients were included, including 229 (69.2%) who received tirofiban administration (tirofiban group) and 102 (30.8%) who received only DAT (non-tirofiban group). Periprocedural TEs occurred in 12 (3.6%) patients, including eight (7.8%) in the non-tirofiban group and four (1.7%) in the tirofiban group. In multivariate analysis, patients receiving tirofiban administration had significantly lower TEs as compared with those who received only DAT (P=0.004). Balloon angioplasty and longer procedure time (>137 min) were also risk factors for TEs. Also, no increase was observed in the rate of HEs related to tirofiban administration.ConclusionsThe current study suggested that prophylactic administration of tirofiban combined with conventional oral DAT seems safe and efficient for preventing TEs during FD treatment of unruptured intracranial aneurysms. Balloon angioplasty and prolonged procedure are associated with a high risk of TEs.

P604 Can we reduce intravenous monoclonal antibody observation times without compromising patient safety? A single centre retrospective observational study

Background Monoclonal antibodies (MAbs) are integral to inflammatory bowel disease (IBD) management. The administration of intravenous (IV) MAbs, infliximab and vedolizumab, for Brighton and Sussex University Hospital patients is via an outpatient clinic. Licensing specifies lengthy observation times; infliximab for induction (infusion 1 to 3) and maintenance (infusion 4 onwards) requires 1 to 2 h observation. Vedolizumab for induction (infusion 1 to 2) requires 2 h observation and maintenance (infusion 3 onwards) 1-h observation. This can affect waiting times; 33% UK patients waited longer than two weeks for infliximab. A reduction in observation times could improve capacity but needs to be done without compromising patient safety. Methods A single centre observational study was conducted. Retrospective data were collected on all current patients receiving infliximab or vedolizumab at BSUH. Data were collected over 12 weeks (April to July 2019); patients seen twice in this period were included once. The presence of reaction from current and previous infusions was determined by patient questioning and patient records review. Reaction occurrence, nature and management were recorded. There is not a grading system for IBD infusion-related reactions. To standardise we used the cancer Common Terminology Criteria for Adverse Events; grade 3 and above is designated severe (grade 5 being death). Results For infliximab 130 patients were reviewed with 2607 infusions administered in total. For vedolizumab 69 patients were reviewed with 557 infusions administered in total. Due to the small sample size significance could not be reached. The survival plot indicates high levels of ‘no reactions’ observed in the first 4 infusions of infliximab 97.7% (+1.6%, -4.7%), and first 3 infusions of vedolizumab 96.9% (+2.3%, −8.8%). Considering capacity over 12 weeks, for infliximab a minimum of 121 could be recouped and 64 h for vedolizumab. Extrapolated this could equate to 740 h per year. Conclusion All reactions occurred within three infusions, were non-severe and managed within the infusion clinic. By removing the observation period from infusion 4 onwards, infusion clinic capacity could be increased but further data from multiple centres are required to prove significance.

Dexmedetomidine versus propofol as a sedative agent in the intensive care unit: a randomized single blinded prospective study

Background: Sedation is an essential prerequisite for every ICU patient. It promotes patient comfort, helps in alleviation of anxiety, stabilizes vitals and reduces the time to extubation and ICU discharge. This study aims at comparing dexmedetomidine versus propofol in ICU sedation with respect to maintenance of vitals, time to extubation, incidence of adverse effects and cost effectiveness.Methods: 60 intubated and mechanically ventilated post-surgical ICU patients were randomly allocated to two groups of 30 each. Group D received dexmedetomidine infusion as a loading dose of 0.1mcg/kg/min IV over 10 minutes followed by maintenance infusion of 0.2-0.7mcg/kg/h IV. Group P received propofol infusion as a loading dose of 5mcg/kg/min IV over 5 minutes followed by a maintenance infusion of 0.3-3mg/kg/h IV. Patients in both groups were maintained at Richmond agitation sedation score of -1 to -2. Measurements of HR, NIBP, SpO2 were taken at regular intervals till cessation of sedation and extubation. Data thus collected was subjected to statistical analysis.Results: Dexmedetomidine was seen to be comparable to propofol as far as maintaining vitals was concerned. Group D (dexmedetomidine) had a statistically significant shorter mean duration to sedation cessation and extubation than group P (propofol). Dexmedetomidine also had the added advantages of minimal respiratory depression, decreased opioid requirements as well as greater cost effectiveness.Conclusions: Dexmedetomidine was found to be a better choice for sedation in the ICU compared to propofol.

Clinical efficacy of dexmedetomidine in two different doses to attenuate the hemodynamic changes during laparoscopic cholecystectomy

Background: Laryngoscopy and laparoscopy lead to predictable hemodynamic changes. Dexmedetomidine is selective 2 agonist with dose dependent sedation, sympatholysis and analgesia, hence could provide stable hemodynamics during laparoscopic surgeries. The present study was aimed to compare the clinical efficacy of dexmedetomidine infusion in two different doses to attenuate the hemodynamic variations during laparoscopic cholecystectomy.Methods: Total 60 adult patients of ASA physical status I and II of both gender, scheduled for elective laparoscopic cholecystectomy, were randomly allocated into two groups of 30 patients. All patients were infused with loading dose of dexmedetomidine (1µg/kg) before induction. Patients of Group 1 received maintenance infusion of dexmedetomidine in doses of 0.3µg/kg/h and patients of Group 2 received maintenance infusion of dexmedetomidine in doses of 0.6µg/kg/h, continued till the end of surgery. Heart rate and blood pressure were recorded preoperatively, after dexmedetomidine administration, after induction, intubation, after creation of pneumoperitoneum and postoperatively. Intraoperative changes in heart rate and blood pressure were noted as primary variables and dexmedetomidine related side effects were noted as secondary outcomes, for statistical analysis.Results: The hemodynamic responses were attenuated in patients of both groups after laryngoscopy, intubation and creation of pneumoperitoneum but patients of Group 2 (0.6µg/kg/h) showed more stability in hemodynamics. The difference between the group was statistically significant (p value=0.001). No any evident complication or side effects occurred.Conclusions: Dexmedetomidine infusion was effective for attenuating the hemodynamic changes due to laryngoscopy and laparoscopy but were better with maintenance infusion of dexmedetomidine in dose of 0.6µg/kg/h.

How does sevoflurane induction, followed by a ketamine maintenance infusion, affect intraocular pressure? Establishment of an anaesthetic protocol for paediatric glaucoma examinations under anaesthesia

Accurate measurement of intraocular pressure (IOP) is essential in paediatric glaucoma management. Children require serial measurements and examination under anaesthesia (EUA). Most anaesthetic agents reduce IOP, and the ideal time to measure IOP under anaesthesia is questionable.Study purposeTo determine the effect of sevoflurane induction, followed by intravenous ketamine infusion on IOP, in children undergoing EUA for glaucoma or suspected glaucoma, and to establish the earliest time point at which reliable, repeatable IOP measurements can be obtained under anaesthesia.MethodA prospective, descriptive study of IOP changes occurring in children requiring EUAs. A standardised anaesthetic protocol: sevoflurane induction, intravenous cannulation, 2 mg/kg intravenous ketamine bolus and 4 mg/kg/hour maintenance for 15 min. IOP measurements (taken supine with a Perkins applanation tonometer) and physiological variables were recorded.ResultsIOPs were measured in 25 children (50 eyes). Twenty-six eyes (52%) were glaucomatous. Mean patient age was 29 months (2–88 months). Physiological variables returned to baseline at 8 min, correlating with recorded sevoflurane elimination. Mean IOP after sevoflurane induction was 3.68 mm Hg lower than with ketamine maintenance at 15 min (95% CI 1.35 to 6.02 mm Hg) (p=0.002). Contrastingly, the difference in IOP between ketamine anaesthesia at 15 min and near wakefulness was 0.28 mm Hg (95% CI −2.23 to 2.79 mm Hg) (p=0.826).ConclusionSevoflurane’s IOP-lowering effect is reversed 15 min after the discontinuation of the inhalational gas, if anaesthesia is maintained with an intravenous ketamine infusion. IOP measurements appear to stabilise at this time point until the point of near wakefulness and may reflect awake values.