BACKGROUND: OFA (Opioid-free anesthesia) has the potential to reduce the occurrence of opioid-related adverse events and enhance postoperative recovery. Our research aimed to investigate whether OFA, combining esketamine and dexmedetomidine, could serve as an alternative protocol to traditional OBA (opioid-based anesthesia) in shoulder arthroscopy, particularly in terms of reducing PONV (postoperative nausea and vomiting).
METHODS: A total of 60 patients treated with shoulder arthroscopy from September 2021 to September 2022 were recruited. Patients were randomly assigned to the OBA group (n = 30) and OFA group (n = 30), receiving propofol-remifentanil TIVA (total intravenous anesthesia) and esketamine-dexmedetomidine intravenous anesthesia, respectively. Both groups received ultrasound-guided ISBPB(interscalene brachial plexus block)for postoperative analgesia.
RESULTS: The incidence of PONV on the first postoperative day in the ward (13.3% vs. 40%, P < 0.05) was significantly lower in the OFA group than in the OBA group. Moreover, the severity of PONV was less severe in the OFA group than in the OBA group in PACU (post-anesthesia care unit) (0 [0, 0] vs. 0 [0, 3], P<0.05 ) and in the ward 24 h postoperatively ( 0 [0, 0] vs. 0 [0, 2.25], P<0.05). Additionally, the OFA group experienced a significantly shorter length of stay in the PACU compared to the OBA group (39.4 ± 6.76 min vs. 48.7 ± 7.90 min, P < 0.001).
CONCLUSIONS: Compared to the OBA with propofol-remifentanil, the OFA with esketamine- dexmedetomidine proved to be feasible for shoulder arthroscopy, resulting in a reduced incidence of PONV and a shorter duration of stay in the PACU.
BACKGROUND: The Chinese Clinical Trial Registry (No: ChiCTR2100047355), 12/06/2021.

BACKGROUND: Remifentanil, an ultra-short-acting µ-opioid receptor agonist, is commonly used for anesthetic management due to excellent adjustability. Remifentanil is known to cause sinus bradycardia, however, because it has a direct negative chronotropic effect on the cardiac conduction system and there is an indirect negative chronotropic effect via the parasympathetic nervous system.
METHODS: An 8-year-old Japanese boy was diagnosed with acute hydrocephalus due to a brain tumor in the fourth ventricle and underwent emergency surgery. Imaging examination showed brainstem compression. Endoscopic third ventriculostomy and ventriculoperitoneal shunt surgery were scheduled. Remifentanil was started during induction of general anesthesia, but electrocardiogram showed sinus bradycardia, then Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was immediately discontinued, and we administered atropine sulfate. Complete atrioventricular block was restored to sinus rhythm. When remifentanil was restarted, however, the electrocardiogram again showed sinus bradycardia, Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was again immediately discontinued, we administered adrenaline, and then complete atrioventricular block was restored to sinus rhythm. Fentanyl was used instead of remifentanil with continuous infusion of dopamine. There has since been no further occurrence of complete atrioventricular block.
CONCLUSIONS: This is the first known case of complete atrioventricular block in a pediatric patient with increased intracranial pressure seemingly caused by administration of remifentanil.

UNASSIGNED: This study aimed to evaluate and compare the effects of sevoflurane + remifentanil (Sev + Rem) and propofol + remifentanil (Pro + Rem) on the postoperative recovery quality of patients undergoing laparoscopic bariatric surgery to determine which anesthesia regimen provides a better overall recovery experience.
UNASSIGNED: Sixty patients were divided into two groups based on the treatments they underwent: Sev + Rem (n = 30) and Pro + Rem (n = 30). The Sev + Rem group received sevoflurane inhalation (0.5%, increasing to 0.5-4%) and remifentanil via target-controlled infusion. The Pro + Rem group received propofol [4-8 mg/(kg·h)] and remifentanil via target-controlled infusion. Anesthesia depth was maintained at a bispectral index of 40-60 in both groups. Perioperative data, hemodynamic parameters, and postoperative recovery quality were assessed.
UNASSIGNED: Compared to the Pro + Rem group, the dose of remifentanil in the Sev + Rem group was significantly lower (1693.67 ± 331.75 vs. 2,959 ± 359.77, p < 0.001), the proportion of patients used norepinephrine was markedly higher [16 (53.33) vs. 8 (26.67), p = 0.035], and the time of extubation was earlier (356.33 ± 63.17 vs. 400.3 ± 50.11, p = 0.004). The Hemodynamic results showed the HR in the Sev + Rem group was faster than that in the Pro + Rem group at the beginning of surgery and 1 h post-surgery (67.37 ± 4.40 vs. 64.33 ± 4.44, p = 0.010, 69.07 ± 4.23 vs. 66.40 ± 5.03, p = 0.030). In regard to the assessment of postoperative recovery quality, the emotional state scores in the Sev + Rem group were significantly lower than the Pro + Rem group (36.83 ± 2.79 vs. 39.50 ± 4.64, p = 0.009).
UNASSIGNED: The two anesthesia modalities (Sev + Rem and Pro + Rem) have their advantages and disadvantages for patients undergoing laparoscopic bariatric surgery and have comparable effects on postoperative recovery quality.

BACKGROUND: While studies comparing the effectiveness of remifentanil and dexmedetomidine are prevalent in other nations, using remifentanil alone is uncommon in Malaysia. This research aims to evaluate the effectiveness of sedation with remifentanil or dexmedetomidine infusion in monitored anesthesia care for electrophysiology procedures.
METHODS: This study is a single-center, single-blinded, prospective randomized clinical study. One hundred twenty patients were randomized into two groups (remifentanil vs dexmedetomidine). Demographic characteristics and clinical outcomes, including level of sedation, vital signs, and patient satisfaction were monitored and recorded.
RESULTS: Group R showed a higher mean observer\'s assessment of alertness/sedation score (3.9 ± 0.7 vs 3.6 ± 0.8; p = 0.008), mean arterial pressure (92.0 ± 12.0 vs 83.0 ± 13.0 mmHg; p < 0.001), heart rate (82.0 ± 20.0 vs 73.0 ± 18.0 beats/min; p = 0.006), systolic blood pressure (139.0 ± 16.0 vs 123.0 ± 17.0 mmHg; p < 0.001) and diastolic blood pressure (75.0 ± 13.0 vs 69.0 ± 14.0 mmHg; p = 0.009) than Group D. Oxygen saturation (99.0 ± 1.0%; p = 0.220) and respiration rate (16.0 ± 3.0 breaths/min; p = 0.361) for both groups were the same. Adverse events, including hypotension, bradycardia, and respiratory depression were observed in both groups. Both groups gave positive responses ranging from fair to good for patient satisfaction.
CONCLUSIONS: Dexmedetomidine is a better choice of anesthesia as it was associated with a higher level of sedation, more stable hemodynamics, lower incidence of adverse events, and better patient satisfaction.

BACKGROUND: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB).
METHODS: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www.
RESULTS: gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects.
RESULTS: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients\' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients.
CONCLUSIONS: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

UNASSIGNED: This study explored the effects of different doses of remimazolam tosilate (RT) and propofol combined with remifentanil anesthesia on hemodynamic and inflammatory responses in patients undergoing laparoscopic surgery.
UNASSIGNED: Ninety patients with a BMI of less than 35 kg/m², classified as ASA II-III and scheduled for laparoscopic surgery, were enrolled in this study. Patients were divided into three groups: low-dose RT group (A), high-dose RT group (B), and propofol group (C). The changes in hemodynamic indices such as SBP, DBP, HR, MAP, and inflammatory response indices such as IL-6, SAA, CRP, and PCT, along with extubation time and doses of sufentanil, remifentanil, urapidil, and phenylephrine, were compared among the three groups.
UNASSIGNED: There were no statistically significant differences in extubation time, doses of sufentanil and remifentanil, or the usage rates and average doses of urapidil and phenylephrine between the three groups. The average dose of phenylephrine in group A was lower than in group B and group C, with a statistically significant difference. There were no statistically significant differences among the groups in SBP, DBP, HR, and MAP from T0 to T2, nor in IL-6, SAA, CRP, or PCT levels.
UNASSIGNED: Using RT for induction and maintenance of anesthesia in laparoscopic surgery ensures stable hemodynamic and inflammatory responses in patients. Low-dose RT may reduce the usage rate and dose of vasopressors such as phenylephrine during surgery.

This study aimed to explore the regulatory effect of remifentanil-mediated mitochondrial autophagy on osteoclast formation and further investigate its mechanism. Macrophage cell line RAW264.7 was taken and induced to differentiate into mature osteoclasts using nuclear factor kB receptor activating factor ligand (RANKL). The cell model was treated with different concentrations of remifentanil or down-regulated expression of mitochondrial autophagy-related gene PINK1. The survival, death and ROS production of osteoclasts were detected by CCK8 kit and flow cytometry, MMP level was detected by JC-1 method, mitochondrial morphology and autophagy were observed by transmission electron microscopy, and mitochondrial autophagy-related protein expression was detected by Western blot. The number of osteoclasts in the remifentanil-treated group was significantly reduced compared to the control group, accompanied by a reduction in reactive oxygen species (ROS) and mitochondrial membrane potential levels (MMP). Further results showed that remifentanil could significantly up-regulate the activity of PINK1/Parkin pathway, promote the occurrence of mitochondrial autophagy, and damaged mitochondria, and inhibit the formation of osteoclasts. Remifentanil successfully inhibited osteoclast formation by regulating mitochondrial autophagy mediated by PINK1/Parkin pathway. The results of this study revealed that remifentanil plays an important role in the physiology and pathology of osteoclasts, which may provide new ideas and strategies for the clinical treatment of remifentanil in tibial fractures.

OBJECTIVE: Abundant data are available on the effect of the A118G (rs1799971) single-nucleotide polymorphism (SNP) of the μ-opioid receptor OPRM1 gene on morphine and fentanyl requirements for pain control. However, data on the effect of this SNP on intraoperative remifentanil requirements remain limited. We investigated the effect of this SNP on intraoperative remifentanil requirements.
METHODS: We investigated 333 Japanese women, aged 21-69 years, who underwent laparoscopic gynecological surgery for benign gynecological disease under total intravenous anesthesia at Juntendo University Hospital. Average infusion rates of propofol and remifentanil during anesthesia and the average bispectral index (BIS) during surgery were recorded. Associations among genotypes of the A118G and phenotypes were examined with the Mann-Whitney U test.
RESULTS: The average propofol infusion rate was not different between patients with different genotypes. The average remifentanil infusion rate was significantly higher in patients with the AG or GG genotype than the AA genotype (p = 0.028). The average intraoperative BIS was significantly higher in patients with the GG genotype than the AA or AG genotype (p = 0.039).
CONCLUSIONS: The G allele of the A118G SNP was associated with higher intraoperative remifentanil requirements and higher intraoperative BIS values but was not associated with propofol requirements. Given that remifentanil and propofol act synergistically on the BIS, these results suggest that the G allele of the A118G SNP is associated with lower effects of remifentanil in achieving adequate intraoperative analgesia and in potentiating the sedative effect of propofol on the BIS.

BACKGROUND: Acute appendicitis (AA) is the most common cause of acute abdomen in children. Anesthesia significantly influences the surgical treatment of AA in children, making the scientific and effective selection of anesthetics crucial.
OBJECTIVE: To assess the clinical effect of atropine (ATR) in combination with remifentanil (REMI) in children undergoing surgery for AA.
METHODS: In total, 108 cases of pediatric AA treated between May 2020 and May 2023 were selected, 58 of which received ATR + REMI [research group (RG)] and 50 who received REMI [control group (CG)]. Comparative analyses were conducted on the time to loss of eyelash reflex, pain resolution time, recovery time from anesthesia, incidence of adverse events (AEs; respiratory depression, hypoxemia, bradycardia, nausea and vomiting, and hypotension), intraoperative responses (head shaking, limb activity, orientation recovery, safe departure time from the operating room), hemodynamic parameters [oxygen saturation (SPO2), mean arterial pressure, heart rate, and respiratory rate], postoperative sedation score (Ramsay score), and pain level [the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale].
RESULTS: Compared with the CG, the RG showed significantly shorter time to loss of eyelash reflex, pain resolution, recovery from anesthesia, and safe departure from the operating room. Furthermore, the incidence rates of overall AEs (head shaking, limb activity, etc.) were lower, and influences on intraoperative hemodynamic parameters and stress response indexes were fewer. The Ramsay score at 30 min after extubation and the FLACC score at 60 min after extubation were significantly lower in the RG than in the CG.
CONCLUSIONS: ATR + REMI is superior to REMI alone in children undergoing AA surgery, with a lower incidence of AEs, fewer influences on hemodynamics and stress responses, and better post-anesthesia recovery.

Objective: To analyze the consistency of the anesthesia index (AI) and Narcotrend index (NI) in monitoring the depth of anesthesia in pediatric tonsil/adenoidectomy. Methods: A total of 129 children who underwent elective tonsil/adenoidectomy at Xijing Hospital Affiliated to Air Force Medical University from July 2022 to October 2023 were prospectively enrolled. Both AI monitoring by ConView monitor and NI monitoring by Narcotrend monitor were conducted for children after they were admitted to the operating room, while Propofol-remifentanil combined with total intravenous anesthesia was used during the operation and the anesthetic dose was adjusted to maintain the NI value at 40-60. In addition, the AI and NI values were recorded at following time points: quiet eyes closing (T1), the beginning of induction (T2), loss of consciousness (T3), tracheal intubation (T4), the beginning of surgery (T5), during tonsil excision (T6), adenoidectomy (T7), the end of surgery (T8), consciousness recovery (T9) and tracheal extubation (T10). Bland-Altman consistency analysis was used to evaluate the consistency of the results of the two types of anesthesia depth monitoring, AI value and NI value. Receiver operator characteristic (ROC) curve and area under curve (AUC) were used to analyze the predictive efficacy of AI and NI values for the state of consciousness of children. The intraoperative awareness was followed up at 24 hours, 1 week and 1 month after surgery. Results: In 129 cases, there were 78 boys and 51 girls, with an average age of (7.2±3.2) years and an operation time of (72.8±14.0) min. No AI data were missing, but 13 NI data were missing, with a missing rate of 10.1% (13/129). At time points T1-T10, the AI values were 67.5±19.2 and the NI values were 67.2±19.2. Bland-Altman consistency analysis showed that the difference in value between AI and NI was 0.3 (95%CI:-0.1-0.6, P=0.120), with an out-of-consistency range of 4.0% (51/1 290). Before anesthesia induction, AI and NI values were maintained at a high level; with the beginning of anesthesia induction and the disappearance of the children\'s consciousness, both AI and NI values gradually decreased; after discontinuing the infusion of anesthetics, the values of AI and NI gradually increased, and the change trend of AI and NI in each stage of the perioperative period was consistent, and there was no significant difference between the two groups at each time point (all P>0.05). ROC curve analysis showed that the cut-off value for predicting the state of consciousness using AI was 72.5, with an AUC of 0.73 (95%CI: 0.70-0.75), and the cut-off value of NI was 79.5 and the AUC was 0.74 (95%CI: 0.72-0.77). There was no significant difference in AUC between the two indices (P=0.310). None of the children had intraoperative awareness. Conclusion: Both AI and NI can be used to monitor the depth of anesthesia in pediatric tonsil/adenoidectomy with high accuracy.
目的： 分析麻醉指数（AI）与Narcotrend指数（NI）监测小儿扁桃体/腺样体切除术中麻醉深度的一致性。 方法： 前瞻性纳入2022年7月至2023年10月空军军医大学附属西京医院接受择期扁桃体/腺样体切除术的患儿129例。所有患儿入手术室后均同时采用ConView监测仪进行AI监测，采用Narcotrend监测仪进行NI监测，采用丙泊酚-瑞芬太尼复合全凭静脉麻醉，术中调节麻醉药物剂量，使NI维持在40~60。记录患儿安静闭眼时（T1）、诱导开始时（T2）、意识消失时（T3）、气管插管时（T4）、手术开始（T5）、扁桃体切除（T6）、腺样体刮除（T7）、手术结束（T8）、意识恢复（T9）、气管拔管（T10）10个时间点的AI及NI。采用Bland-Altman一致性分析评价AI和NI两种麻醉深度监测结果的一致性。采用受试者工作特征（ROC）曲线及曲线下面积（AUC）分析AI及NI对患儿意识状态的预测效能。在术后24 h、术后1周及1个月进行术中知晓情况随访。 结果： 129例患儿中，男78例，女51例，年龄为（7.2±3.2）岁，手术时间为（72.8±14.0）min。AI数据无缺失，NI数据缺失13项，缺失率为10.1%（13/129）。在T1~T10时间点的AI为67.5±19.2，NI为67.2±19.2，Bland-Altman一致性分析结果显示，AI与NI差值为0.3（95%CI：-0.1~0.6，P=0.120），一致性范围外占比4.0%（51/1 290）。患儿进行麻醉诱导前，AI和NI均维持在较高水平；随着麻醉诱导开始，患儿意识消失，AI和NI均逐渐降低；停止泵注麻醉药后，AI和NI均逐渐升高，二者在围手术期各个阶段变化趋势一致，且两组数据各时间点比较差异均无统计学意义（均P>0.05）。ROC曲线分析结果提示，AI预测意识状态的cut-off值为72.5，AUC为0.73（95%CI：0.70~0.75），NI预测意识状态的cut-off值为79.5，AUC为0.74（95%CI：0.72~0.77），两种指数的AUC差异无统计学意义（P=0.310）。所有患儿均无术中知晓的发生。 结论： AI和NI均可用于小儿扁桃体/腺样体切除术中麻醉深度的监测，准确性较高。.