J Dent Anesth Pain Med.  2015 Dec;15(4):221-227.

Optimal effect-site concentration of remifentanil for minimizing cardiovascular changes caused by fiberoptic nasotracheal intubation

• Kim EJ
• Jeon HW
• Kim TK
• Baek SH
• Yoon JU
• Yoon JY

Abstract

BACKGROUND
Endotracheal intubation induces clinically adverse cardiovascular changes. Various pharmacological strategies for controlling these responses have been suggested with opioids being widely administered. In this study, the optimal effect-site concentration (Ce) of remifentanil for minimizing hemodynamic responses to fiberoptic nasotracheal intubation was evaluated.
METHODS
Thirty patients, aged 18-63 years, scheduled for elective surgery were included. Anesthesia was induced with a propofol and remifentanil infusion via target-controlled infusion (TCI). Remifentanil infusion was initiated at 3.0 ng/mL, and the response of each patient determined the Ce of remifentanil for the next patient by the Dixon up-and-down method at an interval of 0.5 ng/mL. Rocuronium was administered after propofol and remifentanil reached their preset Ce; 90 seconds later fiberoptic nasotracheal intubation was initiated. Non-invasive blood pressure and heart rate (HR) were measured at pre-induction, the time Ce was reached, immediately before and after intubation, and at 1 and 3 minutes after intubation. The up-and-down criteria comprised a 20% change in mean blood pressure and HR between just prior to intubation and 1 minute after intubation.
RESULTS
The median effective effect-site concentration (EC50) of remifentanil was 3.11 ± 0.38 ng/mL by the Dixon's up-and-down method. From the probit analysis, the EC50 of remifentanil was 3.43 ng/mL (95% confidence interval, 2.90-4.06 ng/mL). In PAVA, the EC50 and EC95 of remifentanil were 3.57 ng/mL (95% CI, 2.95-3.89) and 4.35 ng/mL (95% CI, 3.93-4.45). No remifentanil-related complications were observed.
CONCLUSIONS
The EC50 of remifentanil for minimizing the cardiovascular changes and side effects associated with fiberoptic nasotracheal intubation was 3.11-3.43 ng/mL during propofol TCI anesthesia with a Ce of 4 ug/mL.

Keyword

Nasotracheal intubation; Propofol; Remifentanil

MeSH Terms

Analgesics, Opioid
Anesthesia
Blood Pressure
Heart Rate
Hemodynamics
Humans
Intubation*
Intubation, Intratracheal
Methods
Propofol
Analgesics, Opioid
Propofol

Figure

• 

  Fig. 1 Up-and-down sequence. A successful response was defined as the increase of heart rate (HR) and mean blood pressure (MBP) 1 minute after nasotracheal intubation with a fiberscope that did not exceed 20% of the value just before intubation. If HR or MBP exceeded 20% of the pre-intubation value, it was defined as a failed response. A change between consecutive successful and failed responses is a "crossover" with a midpoint concentration between the successful and failed concentrations (arrows). Seven crossovers were averaged to determine the median effective effect-site concentration of remifentanil.

• 

  Fig. 2 The effect-site concentration and response curves of remifentanil from the probit analysis. EC50 is 3.43 ng/mL (95% confidence interval [CI], 2.90-4.06 ng/mL) and EC95 is 4.52 ng/mL (95% CI, 3.96-9.03 ng/mL).

• 

  Fig. 3 Changes in heart rate (HR) and mean blood pressure (MBP). Data presented as mean ± SD. Baseline (B): before administration of drug, After infusion (tCe): after effect-site target concentration (Ce) of both propofol and remifentanil reached target concentration, Immediately after intubation (I0): right after nasotracheal intubation with fiberscope. * P < 0.05 as compared with tCe.

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