T O T A L I N T R A V E N O U S A N E S T H E S I A W I T H S P O N T A N E O U S B R E A T H I N G F O R T R A N S V A G I N A L O O C Y T E R E T R I E V A L F. Y ı l m a z G ö ğ ü ş , M . D . / A b d u r r a h m a n Y a y c ı, M . D . / Z e y n e p E ti, M . D . D e p a r t m e n t o f A n a e s t h e s io lo g y a n d R e a n im a t io n , S c h o o l o f M e d ic in e , M a r m a r a U n iv e r s ity , I s ta n b u l, T u rk e y . A B STR A C T
O b je c tive : The aim of this study w as to compare the adequacy of spontaneous breathing and assisted ventilation with laryngeal m ask airway (LMA) during total intravenous anesthesia for transvaginal oocyte retrieval.
M ethod s: One hundred patients, undergoing transvaginal oocyte retrieval under propofol - alfentanil anesthesia were randomly assigned into two groups. A nesthesia w as induced with 2 mg.kg-1 propofol and 10 pg.kg-1 alfentanil i.v. in all patients . The ventilation w as assisted with LMA in group I and w as spontaneous in group II. One mg.kg-1 propofol and 5 pg.kg-1 alfentanil i.v. were administered when needed. Systolic and diastolic blood p re ssu re, heart rate, oxygen saturation (S p 0 2) and end-tidal C 0 2 pressure ( E T C 0 2), total drug doses adm inistered, side effects and Aldrete re co ve ry sco re w ere recorded.
R e s u lt s : Blood p re ssu re and heart rate
d ecre ase d significantly in all patients after induction (p<0.001). S p 0 2 increased and E T C 0 2 decreased significantly at the 5th min in group I. S p 0 2 in group I and E T C 0 2 in group II w as found significantly higher (p<0.001) but remained within normal range during the operation. There were no differences in the time to achieve an Aldrete recovery score of 10 and the incidence of side effects.
C o n c lu s io n : W e concluded that propofol- alfentanil ane sth esia with spontaneous breathing
is an effective and safe anesthetic technique for transvaginal oocyte retrieval.
K e y W o r d s : In traven o us a n a e s th e tic s , Propofol, Alfentanil, Transvag inal oocyte retrieval
IN T R O D U C T IO N
Ultrasound-guided tran svag in al fo llicular
aspiration has becom e the preferred method for in vitro fertilization program m es. It is generally accepted a s a painful procedure and there have been several reports on the efficacy and side effects of different anesthetic and an a lg e sic drugs including propofol or thiopental alone (1-3), propofol-fentanil (4), midazolam-remifentanil (4) and m idazolam -fentanil (5) in the literature. However, the adequacy of airw ay m anagem ent technique and the mode of ventilation during the procedure have not been studied.
The aim of this study w a s to evaluate the safety of the airw ay and the adequacy of g as exchange in patients undergoing tran sv ag in al oocyte retrieval under propofol and alfentanil an e sth e sia without an artificial airw ay and to com pare with the patients w hose ventilation w a s a ssisted with laryngeal m ask airw ay (LM A ).
M E T H O D S
After Faculty Ethic Committee approval and the patients’ written consent, 100 fem ale patients,
(Accepted 25 July,
2002)
Marmara Medical Journal 2002,15(4):244-247
Correspondence to: F. Yılmaz Göğüş, M. D, - Department ot Anaesthesiology and Reanimation, School ot Medicine, Marmara University Hospital,
Tophanelioğlu Cad. No: 13-15 Attunizade 81190 Istanbul, Turkey,
e.mail address: emineeti@superposta.com
2 4 4Intravenous anesthesia with spontaneous breathing for transvaginal oocyte retrieval
A S A l-ll and undergoing transvaginal oocyte retrieval, w ere random ly a ssig n e d into two
groups (50 p atien ts in e ach group). No
premedication w a s adm inistered.
A n esth esia w a s induced with 2 m g .k g 1 propofol and 10 pg.kg-1 alfentanil i.v. in all patients. In group I; an appropriate LM A w as inserted and ventilation w a s assiste d to maintain end-tidal C 0 2 p re ssu re ( E T C 0 2) between 35-40 mmHg. In group II; the patients w ere permitted to breathe spontaneously. During a n e sth e sia , 1 mg.kg-1 propofol and 5 p g 'k g 1 alfentanil i.v. w ere adm inistered w hen needed and all patients were
given 10 0 % oxyg en . T h e requirem ent of
alfentanil w a s determined according to the half time of the drug and the requirement of propofol w as determined according to the clinical signs of inadequate a n e sth e sia such a s hypertension, tachycardia, m ovem ent or sw eating.
In all p atien ts, sy sto lic and d iasto lic blood pressure, heart rate, oxygen saturation (S p 0 2)
and in group I, E T C 0 2 p re ssu re w ere
continuously monitored. In group II, E T C 0 2 pressure w a s monitored using a sam ple line
attached at the connection betw een the
breathing circuit and a face m ask fitted to the patient’s face at 5 minute intervals.
In all patients, before and after induction, systolic and diastolic blood pressure and heart rate S p 0 2 and E T C 0 2 values at w ere recorded 5 minute intervals. Total propofol and alfentanil doses administered, duration of anesthesia, side effects and the time to achieve an Aldrete recovery score of 10 were also recorded.
Th e d e cre ase of more than 30% of control values in blood p ressure and heart rate w ere defined as hypotension and bradycardia. Desaturation w as defined a s a S p 0 2 value of le ss than 95% .
Data are exp ressed as mean values ± standard deviatio ns (S D ). C o ntinuous va ria b le s w ere compared with two-way repeated m easures of a n alyses of variance. Mann Whitney-U test was performed for unpaired data. A p<0.05 w as accepted a s statistically significant.
RESULTS
The two groups were sim ilar with regard to demographic patient characteristics (Table I). A n e sth e sia duration w a s found significantly shorter in group I (p<0.001) (Table I). Total propofol dose in group II and alfentanil dose in group I w as significantly higher (Table I).
In all patients, systolic, diastolic blood pressure and heart rate d e cre a se d significantly after induction (p<0.001) (Table II). The decrease in diastolic blood pressure and heart rate w as significantly higher in group I (p<0.001) (Table II).
S p 0 2 in cre ase d and E T C 0 2 d e cre ase d
significantly at the 5lh min in group I (p<0.001). S p 0 2 valu es of group I were significantly higher than those of group II and the E T C 0 2 values of group II were found to be significantly higher than those of group I (p<0.001) although the values w ere within normal ranges during surgery in all patients (Table III).
T a b l e I: D e m o g ra p h ic p a tie n t c h a ra c te ris tic s , d u ra tio n of a n e s th e s ia , to ta l d o s e s o f p ro p o fo l an d a lfe n ta n il ( M e a n iS D )
GROUP I GROUP II
Age (year) 33.10±6.90 33.08+4.86
Weight (kg) 62.78±8.27 62.34+10.13
Duration of anesthesia (min) 25.70t10.92' 38.70±18.75
Total propofol dose (mg) 199.80±86.13 342.50±11.90'
Total alfentanil dose (pg) 859.00±17.60' 690.20±20.70 *p<0.001
T a b l e II: S y s to lic , d ia s to lic b lo o d p re s s u re (m m H g ) a n d h e a rt rate (b e a t/m in ) (m e a n ± S D )
GROUP I GROUP II
Before induction After induction Before induction After induction
Systolic pressure 130.30±17.20 99.50±11.30 * 130.70±15.10 100.90+10.80 '
Diastolic pressure 81 90±11.10 59.60±9.00 ' # 81 20±10.40 65.10±9.50 *
Heart rate 94.40±11.90 70.80+12.30 ' # 97.20±14.10 88.90±10.90 '
' p< 0.001 intragroup # p< 0.001 between the groups
F .
Yilmaz Gögü§, el al
T a b le III: Sp02 and ETCO2 values (mean±SD)
Sp02 (%) ETC02 (mmHg)
Group I Group II Group I Group II
After induction 97.85±0.60 97.60±0.90 39.20±1.00 39.10±2.00 5. min 99.10±0.50* # 98.40±0.75 34.10±1.10 * 38.20±1.90 # 10. min 99.00í0.50‘ # 98.50±0.60 33.40±2.00‘ 37.30±2.10 # 15. min 99.00±0.40* # 97.00±0.55 35.10±2.10* 39.10±1.70 # 20. min 99.10±0.45‘ # 97.90±0.90 36.20±1.70* 40.20±1.60 # 25. min 99.30±0.48‘ # 97.80±0.85 34.70±2.50* 39.50t2.90 # 30. min 99.10±0.55* # 97.70±0.80 34.60±2.10* 38.70±2.50 # 35. min 99.15±0.60* # 98.40+0.50 35.10±2.15 * 39.10±2.00 # ■p<0.001 intragroup # p< 0.001 between groups
There w as no difference in the mean time to achieve an Aldrete recovery score of 10 between
the groups (5 .3 ± 2 .0 and 5.1 ± 1 .6 min
respectively) (p>0.05).
There w as no difference in the incidence and severity of side effects. In group I, hypotension in 3 patients, b rad ycard ia in 9 patients and bronchospasm in 1 patient were observed. In group II, 2 patients had bradycardia. None of the patients required pharm acological therapy.
D IS C U S S IO N
The primary aim of this study w as to evaluate whether assisted ventilation with an artificial airway such as LMA or face m ask w as necessary
to obtain efficient g as exch an g e during
intravenous anesthesia proposed in the literature for transvaginal oocyte retrieval. According to the
va lu e s of S p 0 2 and E T C 0 2 p re ssu re we
obtained in spontaneously breathing patients and the clinically unimportant and limited side effects in this group, we suggested that the use of artificial airw ays such a s endotracheal tube, LMA or face m ask is not n e ce ssa ry during such procedures.
Ram sew ak et al (6) in their study comparing fentanyl and placebo administration to determine the requirem ent of a n a lg e sic agents during transvaginal ultrasound guided follicule aspiration concluded that analgesia is not required during this procedure. B e s id e s it w a s shown that analg esic and/or anesthetic agents such as halotane, droperidol and fentanyl causing increased plasm a prolactin levels and decreased
plasm a progesterone levels had negative effects on the outcom e of in vitro fertilization (7 ). However, according to the results of numerous studies searching for the appropriate analgesic and anesthetic method for transvaginal oocyte retrieval in the literature, it w a s g en erally accepted a s a painful procedure (1-5). Therefore the negative effects of pain on the patient and the negative outcome of the fertilization programme should be prevented by the administration an appropriate and minimally invasive anesthetic. In this study, we did not primarily evaluate the efficacy of propofol-alfentanil an e sth e sia. There have been several studies evaluating the efficacy of the intravenous a ne sth etic ag ents during transvaginal oocyte retrieval in the literature. Propofol and alfentanil have been shown to be appropriate for this outpatient procedure and to be sa fe regarding the outcom e of in vitro fertilization (1-4). Total d o ses of propofol and alfentanil adm inistered in our study, duration of ane sth esia and the incidence and severity of side effects observed w ere com parable with the results of sim ilar studies (1-3). W e thought that shorter duration of an e sth esia resulted in a lower total dose of propofol and the p resence of an artifical airw ay n ecessiated a higher total dose of alfentanil in the LM A group. Th e shorter duration of ane sth esia in group I w a s thought to be related to the patients’ characteristics.
T h e a irw ay m anag em en t te ch n iq u e s have specific com plications. Although endotracheal intubation is the world-w ide a ccep ted gold
standard for a irw ay m anag em ent, it h as
num erous well-known com plications su ch as hem odynam ic s tre s s re sp o n se , dental and
Intravenous anesthesia with spontaneous breathing for transvaginal oocyte retrieval
m ucosal injuries, traum a to the larynx, pharynx and esophagus, traum a to the uvula due to the pressure of the tube (8), tongue edem a due to pressure or ven o u s obstruction, loss of taste sensation due to p ressure of the lingual nerve (9), vocal cord p aralysis with m isplaced cuff pressure (10), vocal cord granulom a with an in cid en ce of 1/800-1/20000 (1 1 ), subglottic edem a and tracheal laserations. Although LMA is le ss invasive than a tracheal tube, its insertion is not without com plications. It has been shown that the use of LM A is a sso ciated with 10% sore throat a s a result of pharyngeal pressure (12),
4%
disphagia (13), 12% h o a rse n e ss (14), 2%oropharyngeal trau m a (15) and traum a to tongue, lingual, recu rren t and hypoglossal nerves (1 6 ,1 7 ). T h e rate of morbidity with the use of artificial airw ays lead s anesthetists to permit patients to breathe with their physiologic airw ays w henever it is possible according to the type of surgery and anesthetic technique used.
In our study, the E T C 0 2 and S p 0 2 values of patients breathing spontaneously remained in physiologic limits although they were different from those of the patients ventilated with LMA. T h e se results indicated that the airw ay w as se cu re d and g a s e x c h a n g e w a s adequate without an artificial airw ay device.
W e co nclud ed that propofol and alfentanil a n e sth e sia ca n be m aintained sa fe ly with sp o n tan eo u s ventilation without an artificial airw ay during ultrasound-guided transvaginal oocyte retrieval.
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