Anesthesia Effect of Remifentanil Combined With Propofol for Elective Small and Medium-Sized Operations in Patients with Uncontrolled Hypertension

Research Article

J Pediatri Endocrinol. 2023; 8(1): 1058.

Anesthesia Effect of Remifentanil Combined With Propofol for Elective Small and Medium-Sized Operations in Patients with Uncontrolled Hypertension

Ziye Jia¹; Xiaohan Liu²; Zihan Lei²; Daoqin Gao¹; Ningning Yang¹; Enjun Lei¹*

1Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China

2Department of Medicine, Graduate School, Nanchang University, Nanchang, PR China

*Corresponding author: Enjun Lei Department of Anesthesiology, the First Affiliated Hospital of Nanchang University, Nanchang, PR China. Email: leienjun@126.com

Received: July 13, 2023 Accepted: August 19, 2023 Published: August 26, 2023

Abstract

Objective: To observe the anesthetic effect of remifentanil and propofol in selective small and medium-sized operation for uncontrolled hypertension patients.

Methods: From September 2021 to October 2022, 86 patients with uncontrolled hypertension were selected for elective small and medium-sized operations, including 2 patients with hypertension and coronary heart disease, 15 patients with hypertension and abnormal electrocardiogram, 3 patients with hypertension and diabetes, and 2 patients with hypertension and other systemic diseases. All of them planned to undergo elective small and medium operations (LC in 58 cases, colon cancer in 5 cases, thyroid surgery in 10 cases, intracranial glioma in 7 cases, and total hysterectomy in 6 cases). The operation time was 116±80.6min. Patients with ASA1-4 (66 patients with ASA1-2, 16 patients with ASA3, and 4 patients with ASA4) were aged 28-89 years and weighed 48-98 kg. Propofol 2~3mg/kg, sufentanil 0.4~0.6μg/kg, cisatracurium 0.15~0.2mg/kg were induced intravenously, remifentanil (0.3~0.4μg /kg/min) was pumped, atracurium (1~2μg /kg/min) was pumped to maintain muscle relaxation. Target controlled infusion of propofol with effective chamber concentration of 2 to 5μg/ml, general anesthesia was performed to maintain the minimum effective concentration of sevoflurane combined with inhalation at 0.8 to 1.5 alveolar levels in all patients, and intermittent addition of cisatracurium with 2 to 4 mg to maintain appropriate muscle relaxations. SP, DP, HR, SpO2 were recorded before anesthesia, after induction (A), after tracheal intubation (B), during anesthesia (C), and before tracheal extubation (D). The number of cases of recovery within 5 minutes after the operation, severe hypertension, severe hypotension during anesthesia, and serious complications of hypertension after surgery were recorded.

Results: The induction of anesthesia in this group was basically stable. After induction, the decrease of SP and HR was (36.3±11.8%) and (26.9±11.4%), respectively, which were significantly different from those before induction (P<0.01). SP and HR after tracheal intubation were significantly higher than those after induction (P<0.01), but there was no significant difference compared with those before induction (P>0.05). SP and HR decreased slightly during anesthesia, but there was no significant difference compared with those before induction (P>0.05). The levels of SP and HR before tracheal extubation were significantly higher than those before induction (P<0.01). All patients (100%) were fully awake within 5 minutes after the end of operation. There were 2 cases of severe hypertension and 1 case of severe hypotension during the operation. There were no cases of serious complications of hypertension after the operation.

Conclusion: The application of remifentanil and propofol in the anesthesia of uncontrolled hypertension patients undergoing elective small and medium-sized operations has a definite effect, and the method is simple, safe and reliable.

Introduction

Hypertension is one of the problems that anesthesiologists often encounter, 90%–95% of which are primary and the rest are secondary. In general, treatment for hypertension is recommended in patients with blood pressure above 160/100 mmHg with the aim of reducing it to below 140/90 mmHg [1]. Preoperative treatment and control of hypertension is crucial to reduce the incidence of vascular events during surgery, with a target blood pressure of below 138/83mmHg. As hypertension is a chronic disease, its management forms the foundation for perioperative management of patients with hypertension [2]. The study found that hypertensive patients experienced a 4.9% increase in stroke risk for every 10mmHg increase in systolic blood pressure, and a 4.6% increase in stroke risk for every 5mmHg increase in diastolic blood pressure. Uncontrolled hypertension is a significant risk factor for anesthesia, which in turn poses a substantial risk to both anesthesia and surgery. However, with the advancement of clinical pathways and day surgeries, a significant number of patients with uncontrolled hypertension require elective small to medium-sized surgeries. The administration of anesthesia without antihypertensive treatment based on patient and surgeon preferences has sparked controversy between surgery and anesthesiology department. Propofol is a novel intravenous anesthetic with numerous benefits such as adequate sedation, rapid onset, complete recovery, short clearance half-life, and more. It has the ability to minimize cardiovascular reactions during intubation. Propofol has been found to have additional benefits beyond its sedative properties. It can inhibit the Renin-Angiotensin-Aldosterone System (RAAS), resulting in better inhibition of the stress response. Furthermore, propofol has been shown to stabilize hemodynamics and result in fewer postoperative adverse reactions. In order to address the challenge at hand, we conducted a study from September 2021 to October 2022, with the approval of the hospital's ethics committee. We administered a combination of intravenous remifentanil and propofol to 86 patients with uncontrolled hypertension who were undergoing elective small and medium-sized surgeries. The study yielded satisfactory anesthesia effects. Our findings are summarized as follows:

Materials and Methods

General Information

This study included 86 patients with uncontrolled hypertension, classified as ASA1-4 (66 cases of ASA1-2, 16 cases of ASA3, and 4 cases of ASA4), who were between the ages of 28 to 89 years old and weighed between 48 to 98 kg. Among these patients, there were 2 cases of hypertension and coronary heart disease, 15 cases of hypertension and abnormal electrocardiogram, 3 cases of hypertension and diabetes, and 2 cases of hypertension and other systemic diseases. All patients were scheduled to undergo elective small and medium sized surgeries, including LC in 58 cases, colon cancer in 5 cases, thyroid surgery in 10 cases, intracranial glioma in 7 cases, and total hysterectomy in 6 cases. The average operation time was 116±80.6 minutes.

Methods of Anesthesia

Prior to anesthesia, patients did not receive preoperative medication. Upon entering the operating room, their veins were accessed and they were continuously monitored with ECG and SpO2. An intravenous injection of 2-3 mg/kg propofol, 0.4-0.6 g/kg sufentanil, and 0.15-0.2 mg/kg cis-atracurium was administered for induction. Endotracheal intubation was performed using visual laryngoscopy, followed by the use of the Drager anesthesia machine to regulate breathing. Intermittent Positive Pressure Ventilation (IPPV) was carried out with a tidal volume of 8-10 mL/kg and a frequency of 12 times/min. The suction/exhalation ratio was maintained at 1:2 (I:E). During the operation, PETCO2 was kept at 25-35 mmHg. Patients with ASA3 grade and all patients with ASA4 grade had a three-cavity central venous catheter inserted into their right internal jugular vein under ultrasound guidance to monitor Central Venous Pressure (CVP) and guide fluid replacement. Radial artery placement was performed in ASA4 patients and direct arterial blood pressure was monitored. During the surgery, anesthesia was maintained using a combination of intravenous remifentanil (0.3-0.4μg/kg/min) and atracurium (1-2μg/kg/min) to keep the patient relaxed. Propofol was also administered through a target-controlled infusion, with an effect chamber concentration of 2-5μg/ml. Sevoflurane was intermittently inhaled to maintain the depth of anesthesia at a BIS value of 40-60. The initial infusion rates were 0.2-0.3ug/kg/min for remifentanil and 50-100ug/kg/min for propofol, and were adjusted as needed based on the patient's response to surgical stimulation. The anesthetic infusion was stopped 5 minutes before the end of the operation.

Monitoring and Collection

The patient's spontaneous breathing and oxygen saturation levels were similar to pre-anesthesia levels, and remained above 95% for 5 minutes after sputum aspiration. Once adequate aspiration was achieved, the endotracheal tube was removed. Patients with ASA grades 1-3 were discharged to the ward, while those with ASA grade 4 were transferred to the ICU for further monitoring and treatment. Record the SP, DP, HR, and SpO2 values before anesthesia (N), after induction (A), after intubation (B), during anesthesia (C), and before tracheal extubation (D). The study recorded the number of cases of patients who recovered within 5 minutes after surgery, experienced severe hypertension or severe hypotension during anesthesia, and had severe complications of postoperative hypertension. Additionally, the number of patients who woke up within 5 minutes after the operation was also recorded.

Statistical Processing

The statistical analyses were conducted using SPSS 19.0. The measurement data were presented as mean ± standard deviation (X±S). We used t-test to compare between groups and chi-square test to compare count data. We considered P<0.05 as statistically significant.

Results

The induction of anesthesia in the observed group was relatively smooth. The Systolic Pressure (SP) and Heart Rate (HR) decreased by 36.3±11.8% and 26.9±11.4%, respectively, after induction, which was significantly different from the values before induction (P>0.05). During anesthesia, there was a slight decrease in SP and HR, but not significantly different from values before induction (P>0.05). Before extubation, there was a significant increase in SP and HR compared to before induction (P<0.01). Prior to extubation, both Systolic Pressure (SP) and Heart Rate (HR) exhibited a significant increase, with a notable difference observed from their levels prior to induction (P<0.01). All patients (100%) were fully awake within 5min after operation. There were no cases of severe awareness during operation, 2 cases of severe hypertension and 1 case of severe hypotension, and no case of severe complications of hypertension after operation.

This study examined the experiences of 86 patients with uncontrolled hypertension during operation. Severe fluctuations in circulation, serious complications of hypertension after the operation, awareness during the operation, and recovery within 5 minutes after the operation were all observed and analyzed.

The incidence of severe hypertension during anesthesia and operation was 2.32%, and the incidence of severe hypotension was 1.16%. The full consciousness rate was 100% within 5 minutes after operation.

Discussion

Hypertension is a prevalent disease worldwide, with approximately one in five patients undergoing surgery suffering from it. In the mid-1990s, it was recommended that patients with blood pressure levels above 160/100 mm Hg should receive treatment for hypertension. The goal of this treatment was to reduce the blood pressure levels to less than 140/90 mm Hg. Hypertension is increasingly prevalent in China with about 100 million people affected, accounting for 11.26% of the population. This has led to a rise in non-cardiovascular surgeries amongst hypertensive patients, resulting in a perioperative hypertension incidence of 30%-50%. During induction of general anesthesia, endotracheal intubation can cause hemodynamic instability due to laryngoscope manipulation, endotracheal tube insertion, and pain during intubation, which stimulates the autonomic nervous system, leading to hypertension and tachycardia [3]. Reducing the incidence of perioperative hypertension is crucial in minimizing cardiovascular and cerebrovascular complications during perianesthesia. Anesthesiologists must have a thorough understanding of the pathophysiological changes associated with hypertension during the clearance operation. They should take proactive measures to prevent and treat severe hypertension and hypotension during anesthesia, as doing so can significantly reduce the risk of surgical complications, anesthesia-related issues, and postoperative mortality.

Principles of Elective Surgery for Patients with Hypertension

Hypertensive patients should actively engage in preoperative preparation to improve their tolerance to anesthesia and surgery and reduce the risk of perianesthesia. Ideally, elective surgery should be scheduled after hypertension is controlled, with blood pressure maintained below high normal levels (SP130-139mmHg, DP85-89mmHg). Concurrent diseases should be treated, physiological dysfunction corrected, necessary examinations completed, and vital organ function improved. Additionally, patients should be carefully prepared and their fears and anxieties about anesthesia and surgery should be addressed to reduce the incidence of complications.

Awareness Rate of Patients with Hypertension

The implementation of fast-track and day surgery in hospitals has led to unique scenarios, such as patients being unaware of their hypertension. The awareness, treatment, and control rates of hypertension are crucial factors that impact the treatment and prognosis of the condition. China is a developing country. According to the census results in recent years, the awareness rate, treatment rate and control rate of hypertension in Chinese cities are 36.3%, 17.4% and 4.2%, respectively. In rural areas, it was 13.7 percent, 5.4 percent and 0.9 percent. It is far from the highest awareness rate of hypertension reported abroad (93%-97%). In China, there has been a growing trend towards implementing clinical path, fast channel surgery, and day surgery in recent years. This trend aims to reduce hospitalization time and costs for surgical patients, which has contributed to the low awareness rate of hypertension. In some cases, surgeons are not even aware that their patients have hypertension until blood pressure is detected through continuous monitoring in the operating room during the perioperative period.

Debate on surgery for uncontrolled hypertension patients

According to the principle of anesthesia of hypertensive patients, patients with uncontrolled hypertension should suspend elective surgery. But by this time the patient was already in the operating room and had been prepared for the operation. If the surgery is suspended, it will inevitably be opposed by some patients and their families, and the surgeons are not satisfied with it. It is not conducive to build a harmonious hospital and the public satisfied hospital, and may even cause medical disputes. A study from surgery on whether it is necessary to control blood pressure before abdominal surgery for hypertensive patients shows that pre-operative antihypertensive treatment for grade 1 and grade 2 hypertension does not increase the risk of surgery. In order to ensure the life safety of uncontrolled hypertension patients, anesthesiologists often advocate anesthesia and surgery after regular antihypertensive treatment. Anesthesiologists and surgeons often have heated debates on this issue, which even affect the unity among disciplines.

Anesthetic Management of Patients with Uncontrolled Hypertension

The study of anesthetic methods: It is the inevitable result of medical reform and development that the patients with uncontrolled hypertension undergo elective small and medium-sized surgery. It will become a new research and development direction of anesthesiology to perform anesthesia in hypertension without control treatment before operation. Therefore, it is urgent to study a safe and reliable anesthesia method for patients with uncontrolled hypertension undergoing elective small and medium-sized surgery. In order to solve this anesthesia problem, through animal experiments and clinical studies in our hospital, it was found that remifentanil and propofol intravenous combination can be used successfully for small and medium-sized operation of uncontrolled hypertension patients. The main mechanism is the intravenous combination of remifentanil and propofol, which can achieve a very ideal anesthetic effect, inhibit the circulation itself, and reduce the heart rate and blood pressure to a certain extent. Remifentanil, an opioid receptor agonist, is a new anesthetic drug, which can cause bradycardia, decrease cardiac output, local vasodilation and decrease blood pressure, with a fast effective speed and a short action time [4]. Propofol, as a new intravenous anesthetic, can also inhibit the Renin-Angiotensin-Aldosterone System (RAAS), and the drug metabolism is very rapid, almost no accumulation in the body [5]. When remifentanil and propofol have a good synergistic effect, can achieve good sedative and analgesic effect, can reduce peripheral vascular resistance, can cause a significant reduction in blood pressure and obvious bradycardia [6]. Anesthesia with remifentanil 3ug/L and propofol 2.5mg/L can effectively control blood pressure [7]. Preliminary clinical observation has shown that only that infusion speed of remifentanil and propofol need to be adjusted dure anesthesia surgery, and the systolic blood pressure can be effectively controlled within the range of 90 to 160 mmHg, thereby ensuring the life safety of such patients dure anesthesia surgery, and being an ideal anesthesia method for patients with uncontrolled hypertension [8] addition, the combination of the two methods can not only maintain the stability of intraoperative hemodynamics, but also improve the quality of recovery and reduce complications [9].

Emergency assessment of hypertension before anesthesia: In order to ensure the life safety of patients with uncontrolled hypertension, the anesthesiologist must carry out targeted emergency evaluation. Hypertensive patients are more likely to have hypotensive reactions during anesthesia induction than normal people 10]. Medical, family and social history should be understood as much as possible; Evaluate target organ function and cardiovascular risk factors and comorbidities. Although most of the problems during the perioperative period occur in the undiagnosed and uncontrolled hypertensive patients, as long as the anesthesiologist attaches great importance to it and takes active prevention and treatment for possible risks, the life safety of these patients undergoing surgery can still be well guaranteed.