A desflurane and fentanyl dosing regimen for wake-up testing during scoliosis surgery: Implications for the time-course of emergence from anesthesia

Abstract

The Stagnara wake-up test assesses neurological deficits during scoliosis surgery, and response surface interaction models for opioids and inhaled agents predicts anesthetic drug effects. We hypothesized that there is an optimal desflurane–fentanyl dosing regimen that can provide a faster and more predictable wake-up time, while also ensuring adequate analgesia during wake-up testing. Methods: Twenty-three American Society of Anesthesiologists Class I–II scoliosis patients who received desflurane–fentanyl anesthetic regimens were enrolled in this posthoc study, and their intraoperative drug administration data were collected retrospectively. Desflurane and fentanyl effect site concentrations were calculated using pharmacokinetic models, and converted to equivalent remifentanil–sevoflurane concentrations. Results: Results were fitted into Greco models for predicting the probability of an Observers Assessment of Alertness/Sedation score of <2. At time of wake-up, the models correctly predicted the probability that patients would respond to voice prompts and prodding was approximately 50%. The probability of pain intensity was distributed between 50% and 95%, indicating a low degree of pain at emergence. When comparing subgroups defined by calculated effect-site fentanyl concentrations, the wake-up time in the intermediate concentration group was significantly shorter than that in the high concentration group (p = 0.024). Conclusion: This study provides evidence that desflurane–fentanyl-based anesthesia is conducive to rapid emergence followed by an immediate neurological evaluation. Intermediate fentanyl effect-site concentrations (1–2 ng/mL) at time of wake-up were associated with good balance between rapid emergence and adequate analgesia. Furthermore, we believe that generalizing response surface models to a variety of inhalation agent-opioid combinations using simple relative potency relationships is possible and practical.

Keywords

• desflurane
• fentanyl
• response surface
• scoliosis surgery
• wake-up testing