İn Vitro fertilizasyon uygulaması sırasında sedoanaljezide kullanılan iki farklı Remifentanil infüzyon dozunun etkilerinin karşılaştırılması
Comparison of the Effects of Two Different Remifentanil Infusion Dosage Used In Sedation during In-Vitro Fertilization Procedure
Yazar: HURİYE BEGBURS SARIKAYA
Danışman: DOÇ. DR. LEYLA İYİLİKÇİ
Dokuz Eylül Üniversitesi / Tıp Fakültesi / Anesteziyoloji ve Reanimasyon Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2008
Konu: Anestezi ve Reanimasyon = Anesthesiology and Reanimation

Özet:
Giriş İn vitro fertilizasyon (IVF) rahatsızlık verici ve ağrılı bir işlem olup, sedasyon ve analjezi gerektirir.Amaç: Bu çalışmada IVF uygulanacak olgularda; iki farklı infüzyon dozunda remifentanil (R) uygulaması ile sağlanan sedasyonun, hemodinamik etkilerinin, sedasyon düzeyinin, hasta ve hekim memnuniyetinin karşılaştırılması amaçlanmıştır.Gereç ve Yöntem: Çalışma, Yerel Etik Kurulun izniyle, sedasyon altında IVF uygulanan ASA I-II, 18-40 yaş arası 86 bayan hasta ile prospektif, randomize ve çift kör olarak gerçekleştirildi. Olgular, Grup R1 ve R2 olarak iki gruba ayrıldı. Bazal ölçüm değerleri kalp atım hızı (KAH), ortalama arteriyel basınç (OAB), periferik oksijen saturasyonu (SPO2), solunum sayısı (SS) ve Ramsay Sedasyon Skoru (RSS) kaydedildi. Grup R1'e 0.1 µg.kg-1.dk-1, Grup R2'ye 0.15 µg.kg-1.dk-1 dozunda remifentanil infüzyonu uygulandı. Remifentanil infüzyonunun 2. dakikasında 1 mg/kg propofol intravenöz (IV) yoldan bolus verildi. Olguların RSS'u 3-4 olacak şekilde sedasyona devam edildi. Remifentanil infüzyonunun başlanmasından IVF işleminin sonuna kadar KAH, SAB, DAB, OAB, SPO2, SS uygulanan remifentanil ve propofol dozları, yan etkiler, RSS'u ilk 10 dakika 2 dakika aralıklarla, daha sonra 5 dakika aralıklarla kaydedildi. Postoperatif izlemde, Postanestezik Modifiye Alderete Skorlamasına (PMAS) göre derlenme skorları kaydedildi. Fertilizasyon, cleavage (yumurta çatlaması) ve gebelik oranları ile gebelik sonuçları karşılaştırıldı.Bulgular: Bu çalışmada, gruplar arasında hemodinamik parametrelerden OAB ve KAH' larında istatistiksel olarak anlamlı fark saptanmadı(p>0.05). Desaturasyon ve hipopne istatistiksel olarak anlamlı düzeyde olmasa da sayısal olarak Grup R2'de daha yüksek oranda gözlendi(p>0.05). Apne ise Grup R2`de anlamlı derecede daha yüksek oranda gözlendi(p<0.05) . Grup R2 `de solunum desteği daha fazla uygulandı (p<0.05). Gruplar arasında PMAS'na göre taburculuk skorları açısından anlamlı fark saptanmadı. Hastaların derlenme skorları, yaklaşık 8. dakikada taburculuğa uygun olarak belirlendi. Gruplar memnuniyet düzeyleri açısından değerlendirildiğinde; anestezist memnuniyeti grup R1'de (p<0.05), cerrah memnuniyeti ise grup R2'de daha iyiydi (p<0.05). Hasta memnuniyeti her iki grupta iyi olarak değerlendirildi (p>0.05). Remifentanil kullanımının grup R2'de daha yüksek oranda olduğu gözlendi(p<0,05). Propofol kullanımının ise istatistiksel olarak anlamlı düzeyde olmasa da sayısal olarak grup R1'de daha yüksek oranda olduğu gözlendi (p>0.05). Fertilizasyon, cleavage, klinik gebelik oranları ve gebelik sonuçları açısından farklılık yoktu (p>0.05).Tartışma: In vitro fertilizasyon işleminde kullandığımız 0.1µg.kg-1.dk-1 infüzyon dozunda remifentanil ile sağlanan sedasyon uygulaması, daha satbil solunumsal bulgular sağladı. Kullandığımız her iki remifentanil infüzyonu dozu, hemodinamik olarak stabil bulgular sağlamasının yanında hızlı, sorunsuz derlenme sağladı. Sonuç: In vitro fertilizasyon işlemlerinde remifentanilin propofol ile kombinasyonu günübirlik olarak güvenle kullanılabilir.Anahtar kelimeler: İn vitro fertilizasyon, sedasyon, propofol, remifentanil

Abstract:
Introduction: In vitro fertilization (IVF) is an uncomfortable, painful procedure which requires analgesia and anesthesia.Aim: The aim of the study is to compare the level and hemodynamic effects of sedation, patient and physician satisfactions following sedation induction via two different infusion dosages of remifentanil (R) and additional bolus propofol infusions.Methods: Approval of the Local Ethical Committee was obtained and a double blind prospective randomized study is performed on ASA I-II 86 female patients aged between 18 and 40 years that undergo IVF. Patients were divided into two groups as R1 and R2. Basal measures, heart rate (HR), mean arterial pressure (MAP), arterial oxygen saturation (SPO2), respiration rate (RR) and Ramsay sedation scores (RSS) are noted. Group R1 received 0.1 µg.kg-1.min-1 while Group R2 received 0.15 µg.kg-1.min-1 remifentanil infusion. 1 mg/kg propofol bolus infusion is administered intravenously at second minute of remifentanil infusions. Sedation was maintained for subjects to have a RSS of 3 to 4. HR, MAP, SPO2, RR, RSS, SAP, DAP, side effects, applied remifentanil and propofol doses, SAB, DAB values were recorded from the beginning of remifentanil infusion to the end of IVF procedure at every two minutes for first 10 minutes and every five minutes there after. Postanesthesic Awakening Scores according to Postanesthetic Modified Alderete Scores (PMAS) were noted in postoperative period. Fertilization, cleavage and pregnancy rates together with pregnancy prognoses were compared.Results: There were no statistically significant differences in HR and MAP as hemodynamic parameters among groups (p>0.05). Desaturation and hypopnea were found to be more often in R2, which is not statistically significant (p>0.05). Whereas apnea (p<0.05) was observed more often in R2. Respiratory support need was observed more in R2 (p<0.05). There was not statistically significant difference among groups in discharge scores according to PMAS. Mean awakening scores of the patients yielded that patients were ready for discharge after 8-minutes. When satisfaction levels were compared among groups, it was observed that anesthesiologist?s satisfaction was superior in R1 (p>0.05) where as surgeon?s satisfaction was superior in R2 (p<0.05). Both patient groups revealed good satisfaction levels (p>0.05). Total remifentanil dose was higher in R2 (p<0.05) where as propofol dose used was higher in R1 , which is not statistically significant (p>0.05). There were no differences among groups in fertilization, cleavage and pregnancy rates together with pregnancy prognoses (p>0.05).Discussion: 0.1µg.kg-1.min-1 infusion dose of remifentanil for sedation produced better respiratory results. Both remifentanil doses maintained stabile hemodynamics and enabled fast, uncomplicated recovery.Conclusion: We believe that remifentanil propofol combination can be safely used in day care procedures.Keywords: In vitro fertilization, sedation, propofol, remifentanilComparison of the Effects of Two Different Remifentanil Infusion Dosage Used In Sedation during In-Vitro Fertilization ProcedureHuriye Begburs Sarikaya, Dokuz Eylul University Faculty of Medicine, Anesthesiology and Reanimation DepartmentIntroduction: In vitro fertilization (IVF) is an uncomfortable, painful procedure which requires analgesia and anesthesia.Aim: The aim of the study is to compare the level and hemodynamic effects of sedation, patient and physician satisfactions following sedation induction via two different infusion dosages of remifentanil (R) and additional bolus propofol infusions.Methods: Approval of the Local Ethical Committee was obtained and a double blind prospective randomized study is performed on ASA I-II 86 female patients aged between 18 and 40 years that undergo IVF. Patients were divided into two groups as R1 and R2. Basal measures, heart rate (HR), mean arterial pressure (MAP), arterial oxygen saturation (SPO2), respiration rate (RR) and Ramsay sedation scores (RSS) are noted. Group R1 received 0.1 µg.kg-1.min-1 while Group R2 received 0.15 µg.kg-1.min-1 remifentanil infusion. 1 mg/kg propofol bolus infusion is administered intravenously at second minute of remifentanil infusions. Sedation was maintained for subjects to have a RSS of 3 to 4. HR, MAP, SPO2, RR, RSS, SAP, DAP, side effects, applied remifentanil and propofol doses, SAB, DAB values were recorded from the beginning of remifentanil infusion to the end of IVF procedure at every two minutes for first 10 minutes and every five minutes there after. Postanesthesic Awakening Scores according to Postanesthetic Modified Alderete Scores (PMAS) were noted in postoperative period. Fertilization, cleavage and pregnancy rates together with pregnancy prognoses were compared.Results: There were no statistically significant differences in HR and MAP as hemodynamic parameters among groups (p>0.05). Desaturation and hypopnea were found to be more often in R2, which is not statistically significant (p>0.05). Whereas apnea (p<0.05) was observed more often in R2. Respiratory support need was observed more in R2 (p<0.05). There was not statistically significant difference among groups in discharge scores according to PMAS. Mean awakening scores of the patients yielded that patients were ready for discharge after 8-minutes. When satisfaction levels were compared among groups, it was observed that anesthesiologist?s satisfaction was superior in R1 (p>0.05) where as surgeon?s satisfaction was superior in R2 (p<0.05). Both patient groups revealed good satisfaction levels (p>0.05). Total remifentanil dose was higher in R2 (p<0.05) where as propofol dose used was higher in R1 , which is not statistically significant (p>0.05). There were no differences among groups in fertilization, cleavage and pregnancy rates together with pregnancy prognoses (p>0.05).Discussion: 0.1µg.kg-1.min-1 infusion dose of remifentanil for sedation produced better respiratory results. Both remifentanil doses maintained stabile hemodynamics and enabled fast, uncomplicated recovery.Conclusion: We believe that remifentanil propofol combination can be safely used in day care procedures.Keywords: In vitro fertilization, sedation, propofol, remifentanil