Anesthetic management
Bradycardia, somatic movements, hypothermia, tachycardia, ®, postoperative pain, nausea and vomiting, grimacing, Tachycardia, hypertension, Hypotension
SKIN, NEUROMUSCULAR BLOCKADE, EVENTS, EVENTS, HYPERTENSION, HEMODYNAMIC INSTABILITY
No premedication was administered before the surgery. Because of the patient’s circadian rhythm, all operations began before 11:30 a.m. All patients in the operating room were fitted with intraoperative monitoring devices (e.g., devices for non-invasive arterial BP measurement, pulse oximeter [CARESCAPE monitor B650, GE Healthcare Finland Oy, Finland], electrocardiogram, and entropy monitor [GE Healthcare, Helsinki, Finland]). Forced-air warming blankets were given to all patients to minimize perioperative hypothermia. Before anesthesia induction, a 20 G cannula was inserted into the radial artery after intradermal injection of 2% lidocaine to the contralateral arm, where an intravenous line was placed, and the first blood sampling was performed using the arterial line. In all patients a pulse oximeter sensor for SPI measurement was attached to the index finger of the hand with the intravenous catheter. Prior to anesthesia induction, the baseline values for mean SPI, HR, and mean arterial pressure (MAP) were recorded. All patients were administered balanced anesthesia with sevoflurane and remifentanil. For the induction of general anesthesia, the patients were administered propofol 2 mg/kg and target-controlled infusion (TCI) of remifentanil with target effect-site concentration (CeUsing the previously described methodology, the SPI was automatically calculated on the monitor used in the study [The signs of inadequate anesthesia were defined as follows: somatic movement, such as grimacing, coughing, and effort of breathing, and hemodynamic events, such as tachycardia and hypertension.A rescue medication (additional propofol 20 mg) was administered in both groups when signs of inadequate anesthesia are identified such as somatic movements, such as grimacing, coughing, and effort of breathing during surgery despite state entropy, MAP, HR, or SPI values within the predefined normal range. Events of Hemodynamic instability were identically defined in both groups. Tachycardia was defined as an HR of > 90 beats/min, and hypertension was defined as MAP > 100 mmHg if the baseline MAP was < 83 mmHg or an increase of over 20% of the baseline MAP if it was > 83 mmHg. Bradycardia was defined as HR < 45 beats/min. Hypotension was defined as MAP < 60 mmHg, as previous study’s definition [In the SPI group, the CeIn the conventional group, the signs of inadequate anesthesia were treated by gradually increasing remifentanil (0.5 ng/mL) from 0 to 5 ng/mL of CeSPI, MAP, and HR were recorded just before induction, 1 min, 5 min after intubation, and 5-min intervals from trocar insertion until the end of skin suture. Operation time was defined as the time after trocar insertion up to skin suture. For proper neuromuscular blockade, the neuromuscular function was monitored with acceleromyography using the TOF-Watch SX® (Organon Ireland Ltd, Schering-Plough Corporation, Dublin, Ireland). Rocuronium (5 mg) was additionally applied at the reappearance of T1 (the first response of train-of-four [TOF] stimulation) just until the specimens were removed.Skin suturing was performed after administration of ramosetron 3 mg i.v. for preventing nausea and vomiting. Then, paracetamol 1 g was administered every 8 h intravenously to control postoperative pain in all patients up to 48 h. At the end of the surgery, the administration of sevoflurane and remifentanil was stopped, the fresh gas flow was increased to 8 L/min of oxygen, and sugammadex 2 mg/kg was administered to reverse neuromuscular blockade after confirming a TOF count of 2.