Clinical Topic: Propofol – Remifentanil Sedation

Epidural Anesthesia is becoming increasingly popular for Orthopedic procedures of the lower extremities.  Anesthetists are tasked with keeping the patient comfortably sedated while the Epidural provides adequate anesthesia during the procedure.   The goal is to keep the patient oxygenated and comfortable with hemodynamic stability and a rapid wake up at the end of the case.   An increasing number of anesthetists are finding that the combination of propofol – remifentanil is the answer.

A.A. Samaan and V. Srinivasan published an observational study  done in the Department of Anaesthesia, Diana Princess of Wales Hospital, Grimsby, England.

As reported by the authors: “Regional anaesthesia offers many advantages for major joint replacement surgery of the lower limb. These operations are usually lengthy and carried out on elderly patients. There is a need for effective and controllable sedation with fast recovery profile. This   obviates the need to administer general anaesthesia in addition to the regional anaesthesia. We undertook to evaluate the efficacy and side effects of combined infusions of Propofol and Remifentanil in this clinical set up.”

“This is an observational study of 123 consecutive patients who required joint replacement surgery; primary hip, primary knee, revision hip, revision knee and bilateral hip replacement.  Epidural anaesthesia was performed in 111 patients.  The Epidural site was either high lumbar or low thoracic. The Local Anaesthetic used was Bupivacaine 0.5%, warmed to body temperature, with Adrenaline added to achieve the strength of 1:200,000. The motor and the sensory functions were checked to ensure adequate blockade.”

Patients were sedated during the surgery with a manually controlled Remifentanil infusion (20 mg per ml solution) and a Target Controlled Infusion of Propofol.

The authors conclude “Sedation with Propofol and Remifentanil complemented successful Epidural regional anaesthesia for major joint replacement surgery.  It was especially valuable in prolonged surgery such as in the case of revision hip replacements. This avoided the need for general anaesthesia.  Sedation with Propofol and Remifentanil is associated with minimal side effects, even in prolonged operations of durations up to 260 minutes, provided there is adherence to a carefully titrated dosage.  In our experience the average infusion rate for Propofol was 2.5 mg.kg.hr and 0.02 mg.kg .min for Remifentanil.”

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