Smooth Removal of LMA

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How to Attenuate Coughing Upon Emergence: Is Remifentanil the Answer?Kristen D’Andrea, SRNA, Eric Dinally, SRNA, Greanne Gramling, SRNA Smooth Removal of LMA • Study included 41 patients undergoing uretero-renoscopy via general anesthesia • Randomly assigned to a group in which a remifentanil infusion was maintained at an effect-site concentration of 1.5 ng/mL by TCI during emergence or a control group in which both desflurane and a remifentanil infusion were discontinued during emergence • In both groups, a classic Laryngeal Mask Airway (cLMA) was used and reactions to emergence such as coughing, teeth clenching, gross purposeful movements, breath holding, laryngospasm, and desaturation to SpO2 < 90% were measured • The incidence and number of complications, measured as the previously listed emergence phenomena, were significantly higher in the control group versus the remifentanil group (p = 0.002) • Neither the time to discharge or removal time of the cLMA were delayed as a result of the remifentanil • Özkan, et al., concluded that maintaining an effect-site concentration of remifenantil at 1.5 ng/mL during emergence from anesthesia enabled smooth removal of the LMA without delaying time to discharge The “Skinny” on Remifentanil • Generic name: Ultiva • A lipophilic, piperidine-derived opioid • An ester group is added to its chemical structure, allowing it to be easily and rapidly metabolized in the blood and tissues by esterases • Not dependent on cholinesterase enzymes for metabolism • Structure and metabolism allow for a short duration of action as well as precise and rapid titration without a overwhelming cumulative effect at discontinuation • Remifentanil may be able to prevent complications during emergence from general anesthesia such as: coughing, dyssynchronous breathing, hypertension, and tachycardia • These phenomenon'smay result in complications such as: postoperative hemorrhage, intracranial andintraocular hypertension, or hematoma IV Remifentanil vs. IV Lidocaine • Study analyzed and compared the effects of IV lidocaine and remifentanil during emergence from general anesthesia • 70 female patients undergoing thyroidectomy via general anesthesia with sevofluorane and remifentanil were randomly assigned to either receive IV lidocaine or remifentanil by Target Controlled Infusion upon emergence • Emergence phenomena such as cough and hemodynamic parameters were evaluated • The incidence of cough during emergence was significantly higher in patients who received IV lidocaine versus those who received remifentanil (72.7% vs 20.6%, P<0.001) • The MAP and HR were significantly lower during emergence in patients who received remifentanil • Lee, et al., concluded that during emergence from general anesthesia, Target Controlled Infusion of remifentanil better attenuates responsiveness to the tracheal tube than does IV lidocaine in patients undergoing thyroid surgery Decreased Coughing With Removal of Endotracheal Tube • A prospective, randomized, controlled trial • Total of 105 patients undergoing laryngomicrosurgery were randomly assigned to receive a maintained effect-site concentration of remifentanilvia a target-controlled infusion (TCI) during emergence • Several emergence phenomena were measured including the incidence and grade of cough, emergence time, mean arterial pressure (MAP), heart rate (HR), respiratory rate, oxygen saturation, and postoperative nausea and vomiting • Chang, et al. concluded that maintaining remifentanilat an effect-site concentration between 1ng/ml, 1.5ng/ml, and 2 ng/mL suppressed coughing without serious adverse events • Remifentanil TCI at Ce 1.5 and 2 ng/mL during emergence from anesthesia with propofol and remifentanilprevents cough in patients after laryngomicrosurgery • Conclusion • The use of remifentanil upon emergence may attenuate a patient’s responsiveness to an endotracheal tube and emergence phenomena such as coughing • It is recommended to maintain an effective dose concentration between 1.5 and 2 ng/mL to suppress coughing yet not delay time to recovery • These findings are pertinent to patients undergoing surgeries such as those involving the ear, nose, throat, and abdomen in which preventing coughing, hypertension, and tachycardia are imperative to the surgical outcome References Chang, C.H., Lee, J.W., Choi, J.R., & Shim, Y.H. (2013). Effect-site concentration of remifentanil to prevent cough after laryngomicrosurgery. The Laryngoscope, 123 (12), 3105-3109. Lee, J.H., Koo, B.N., Jeong, J.J., Kim, H.S., & Lee, J.R. (2011). Differential effects of lidocaine and remifentanil on response to tracheal tube during emergence from general anesthesia. British Journal of Anaesthesia, 106 (3), 410-415.  Nagelhout, J. J., & Plaus, K. (2014). Nurse anesthesia (5th ed.). Chicago, IL: W.B. Saunders. Özkan, D., Ergil, J., Alptekin, A., Aktürk, N., Gümüs, H. (2012). Target controlled remifentanil infusion for smooth laryngeal mask airway removal during emergence from desflurane-remifentanil anesthesia. Journal of Anesthesia, 26(3), 369-374.