Remifentanil to Maintain Unresponsiveness While Propofol Concentrations Decline Before Emergence in Two Patients With Prior Emergence Agitation
Jeffrey D. Swenson, G. Colton Gardner, Ken B. Johnson, Evelyn C. Loose, Alastair Eric MoodyBackground
Emergence agitation is an unpredictable and potentially harmful state during recovery from general anesthesia. We describe a pharmacokinetic strategy intended to permit the propofol concentration to decline further before emergence while maintaining unresponsiveness with remifentanil.
Case
Two adults experienced severe emergence agitation after propofol‐remifentanil total intravenous anesthesia. During subsequent procedures, propofol was discontinued well before emergence, and remifentanil was continued or administered intermittently while estimated propofol effect‐site concentrations declined. Both patients subsequently emerged calmly without observed hemodynamic or ventilatory compromise.
Conclusions
These findings are hypothesis‐generating. They suggest that separating the decline in propofol concentration from the time of awakening warrants prospective study as a strategy to reduce emergence agitation in patients with a prior episode. Modeled rather than measured concentrations, uncontrolled clinical factors, and the use of large remifentanil boluses limit any causal or dosing conclusions.