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From the First Department of Anesthesiology, Dokkyo University School of Medicine, Mibu, Tochigi, Japan.
Address correspondence to: Dr. Mio Shinozaki, First Department of Anesthesiology, Dokkyo University School of Medicine, Mibu, Tochigi 321-0293, Japan. Phone: 81-282-86-7089; Fax: 81-282-86-0478; E-mail: mio28{at}mug.biglobe.ne.jp
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Abstract |
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Methods: Propofol was continuously infused during surgery and spinal anesthesia in 15 elderly patients (65–85 yr-old) and 15 younger patients (20–50 yr-old). Infusion rates were adjusted to maintain an appropriate level of sedation using the bispectral index (range 60–70). The sedative infusion was discontinued at the end of surgery. The early recovery times from the end of propofol infusion to opening of eyes on command, sustaining a hand grip, and recall of name were noted. Psychomotor function, as measured by the Trieger’s dot test, was evaluated before anesthesia and 30, 60, 90, 120 min after the end of propofol infusion.
Results: The duration of anesthesia was 142 ± 55 min and 134 ± 61 min in the elderly and younger patients, respectively. No differences were observed in early recovery times between elderly and younger patients (opened their eyes on command, 6.3 ± 4.0 min and 5.2 ± 2.6 min; sustained a hand grip, 7.2 ± 3.9 min and 6.1 ± 3.5 min and recalled their name, 8.0 ± 4.5 min and 6.5 ± 3.8 min, P > 0.05 ). The recovery of psychomotor function in the elderly took longer compared with the younger patients, and psychomotor function in the elderly recovered at 120 min after the end of propofol infusion.
Conclusion: Early recovery times following propofol sedation is similar between elderly and younger patients, but recovery of psychomotor function in the elderly is delayed compared with younger patients.
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Methods |
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The Trieger’s dot test, a psychomotor function test, was performed before and after anesthesia.10 The Trieger’s dot test was conducted by a single anesthesiologist. This test consists of joining together 42 dots by a line which represents a drawing. The number of dots missed (NDM) represent the total number of dots that were not connected. The sum of the distance (SD) represents the cumulative shorter distance (in millimetres) between the drawn line and missed dots. The maximum distance of dots missed (MDDM) represents the longest distance (in millimetres) between the drawn line and missed dots.
All patients were premedicated with atropine sulfate 0.25–0.5 mg im 30 min before the induction of anesthesia. After arriving in the operating room, routine monitoring and venous cannulation were performed. Dural puncture was performed at the L3–L4, or L4–L5 interspace and 0.5% bupivacaine 3–4 mL were injected.
To measure BIS values during propofol infusion, electrodes were placed on the forehead of each patient. The electrodes used were disposable BisSensor® strips (Aspect Medical Systems Inc., Newton, MA, USA). BIS values from the electroencephalogram (EEG) were calculated with an aspect EEG monitor (Model A1050, Aspect Medical Systems, software version 3.3).
A face mask was applied to administer oxygen 3 L•min–1. Propofol infusion was commenced at 6 mg•kg–1•hr–1 for ten minutes via a syringe pump and the infusion rate adjusted to maintain an appropriate level of sedation using BIS values (range 60–70).11,12 The infusion was discontinued at the end of surgery.
The early recovery time (min) from the end of propofol infusion to opening of eyes on command, sustaining a hand grip and recall of name were noted by a single anesthesiologist. The Trieger’s dot test was administered before anesthesia and 30, 60, 90, 120 min after discontinuation of propofol infusion. The presence of any complication was noted, particularly in relation to respiratory or airway problems, nausea or vomiting, and headache.
Data were expressed as mean ± SD. Statistical analyses within a group were performed by repeated-measure analysis of variance (repeated measurement ANOVA) with Bonferroni’s correction. Comparisons between both groups were made by applying the Mann-Whitney test. The threshold for statistical significance was P < 0.05.
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Results |
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. Except for age, no significant difference was found between the two groups. The mean infusion rate of propofol was also comparable in each group. Quality and ease of control of sedation were good in both groups using the BIS values. The values were maintained 60–70 during anesthesia.
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Assessment of early recovery time
Early recovery times were similar in both groups. There was no significant difference in the interval from the end of propofol infusion until patients opened their eyes on command (6.3 ± 4.0 min and 5.2 ± 2.6 min, P > 0.05, in groups E and Y, respectively), sustained a hand grip (7.2 ± 3.9 min and 6.1 ± 3.5 min, P > 0.05, in groups E and Y, respectively) and recalled their name (8.0 ± 4.5 min and 6.5 ± 3.8 min, P > 0.05, in groups E and Y, respectively).
Assessment of the Trieger’s dot test
NDM before and after anesthesia are shown in Figure 1. There was no difference in NDM before anesthesia between the two groups. However, NDM in group E was significantly higher than in group Y from 30–90 min after the end of propofol infusion. In group E, NDM increased significantly compared with baseline values from 30–90 min after the end of propofol infusion. SD and MDDM before and after anesthesia are shown in Figures 2 and 3. There were no significant differences before anesthesia between the two groups. However, significant increases of SD and MDDM in group E were observed from 30–90 min after the end of propofol infusion compared with group Y. In group E, SD and MDDM increased significantly compared with baseline values from 30–90 min after the end of propofol infusion.
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Discussion |
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Propofol has also become a popular agent for sedation following local or regional anesthesia,6,7 because it has a short duration of action and rapid recovery with a minimum of side-effects, including a decreased incidence of nausea and vomiting. In this study, one elderly patient felt nausea postoperatively. Various mental changes, such as elation, euphoria, talkativeness and hallucination also occur after propofol anesthesia. Grant and Mackenzie13 reported that patients anesthetized with propofol woke up with euphoria and talkativeness. In our study, two patients experienced euphoria postoperatively in each group. Such mental changes may affect the results of the Trieger’s dot test.
BIS values, which are derived from the EEG, have been introduced as a measure of the hypnotic level of anesthesia. The values change according to the depth of anesthesia or sedation, and decrease linearly with increasing anesthetic concentrations in patients of all ages.4 The BIS values at which patients are adequately sedated have been determined in many studies. 9,14,15 In the present study, the BIS values were maintained between 60 and 70 during propofol sedation in both groups. Since the recovery of psychomotor function in the elderly is prolonged compared with the younger patients, higher BIS values may be more appropriate in elderly patients.
Various psychomotor indices have been suggested to measure intermediate or late recovery from anesthesia.8,10,11,16,17 Larsen et al.18 measured psychomotor function using choice reaction time and the perceptive accuracy test following propofol and isoflurane anesthesia. They reported that those tests were effective and sensitive in assessing recovery of psychomotor function. Gupta et al.,16 performing the Trieger’s dot test and the p-deletion test to measure psychomotor recovery after propofol and isoflurane anesthesia, found that the Trieger’s dot test was sensitive, but that the p-deletion test could not predict recovery in the individual patient. Thus, the Trieger’s dot test is used widely for the assessment of intermediate and late recovery of cognitive and psychomotor functions after anesthesia.10 However, there are occasions when it is difficult to assess how many dots have been missed and interpretation can be somewhat subjective.16
In conclusion, we found that recovery of psychomotor function after propofol sedation in the elderly was delayed, although early recovery times in the elderly were not different from those of younger patients. Elderly patients may require a more prolonged observation period after cessation of sedation with propofol.
Revision received July 22, 2002. Accepted for publication December 20, 2001.
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2 Schnider TW, Minto CF, Gambus PL, et al. The influence of method of administration and covariates on the pharmacokinetics of propofol in adult volunteers. Anesthesiology 1998; 88: 1170–82.[Medline]
3 Schnider TW, Minto CF, Shafer SL, et al. The influence of age on propofol pharmacodynamics. Anesthesiology 1999; 90: 1502–16.[Medline]
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10 Newman MG, Trieger N, Miller JC. Measuring recovery from anesthesia–a simple test. Anesth Analg 1969; 48: 136–40.[Medline]
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12 Kearse LA Jr, Rosow C, Zaslavsky A, Connors P, Dershwitz M, Denman W. Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis. Anesthesiology 1998; 88: 25–34.[Medline]
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14 Glass PS, Bloom M, Kearse L, Rosow C, Sebel P, Manberg P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997; 86: 836–47.[Medline]
15 Iselin-Chaves IA, El Moalem HE, Gan TJ, Ginsberg B, Glass PSA. Changes in the auditory evoked potentials and the bispetral index following propofol or propofol and alfentanil. Anesthesiology 2000; 92: 1300–10.[Medline]
16 Gupta A, Kullander M, Ekberg K, Lennmarken C. Assessment of recovery following day-case arthroscopy. A comparison between propofol and isoflurane-based anaesthesia. Anaesthesia 1995; 50: 937–42.[Medline]
17 Larsen B, Seitz A, Larsen R. Recovery of cognitive function after remifentanil-propofol anesthesia: a comparison with desflurane and sevoflurane anesthesia. Anesth Analg 2000; 90: 168–74.
18 Larsen LE, Gupta A, Ledin T, Doolan M, Linder P, Lennmarken C. Psychomotor recovery following propofol or isoflurane anaesthesia for day-care surgery. Acta Anaesthesiol Scand 1992; 36: 276–82.[Medline]
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P < 0.05 vs baseline; 
P < 0.01 vs baseline.
