title: Is there a learning curve associated with the use of remifentanil?
abstract: This study prospectively determined whether there was a learning curve with the use of remifentanil, as indicated by decreased hemodynamic variability, improved recovery profile, and decreased incidence of opioid-related adverse events with increasing experience. Patients undergoing diverse surgical procedures (outpatient [n = 1340] and inpatient [n = 560]) were enrolled by investigators (n = 190) who had no previous experience with remifentanil use. Each investigator enrolled 10 patients. A standardized protocol for administration of remifentanil was used. Data were analyzed to determine differences between the first three patients and the last three patients enrolled for each anesthesiologist in the study. There were no differences in hemodynamic variables between the first triad and the last triad in either outpatients or inpatients. Requirements for hypnotic drugs and the doses of remifentanil used were also similar between groups. Analgesic medications administered at the end of surgery and in the postanesthesia care unit (PACU) were similar between groups, except that the last triad in the outpatient group received smaller doses of fentanyl compared with the first triad. Times to response to verbal command, tracheal extubation, and operating room discharge did not differ between groups. However, patients in the last triad undergoing outpatient surgery had shorter times to eligibility for PACU discharge, but times to eligibility for discharge home did not differ. The overall incidence of all adverse events (i.e., hypotension, hypertension, muscle rigidity, respiratory depression, apnea, nausea, and vomiting) was less in the last triad as compared with the first triad. When analyzed separately, only the incidence of vomiting (in the outpatient group) was decreased in the last triad as compared with the first triad. This study suggests that there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of PACU stay.
  
  
  CONCLUSIONS
  This study demonstrated that anesthesiologists rapidly acquire the ability to use remifentanil with limited experience. However, there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of postanesthesia care unit stay.
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas 75235-9068, USA. girish.joshi@email.swmed.edu
authors.forename: G P
authors.initials: GP
authors.lastname: Joshi
authors.forename: B D
authors.initials: BD
authors.lastname: Jamerson
authors.forename: M F
authors.initials: MF
authors.lastname: Roizen
authors.forename: L
authors.initials: L
authors.lastname: Fleisher
authors.forename: R S
authors.initials: RS
authors.lastname: Twersky
authors.forename: D S
authors.initials: DS
authors.lastname: Warner
authors.forename: M
authors.initials: M
authors.lastname: Colopy
mesh_terms: D000328:Adult; D000556:Ambulatory Surgical Procedures; D000700:Analgesics / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects; D000762:Anesthesia Recovery Period; D018686:Anesthetics, Intravenous / Q000009:adverse effects; D002983:Clinical Competence; D002985:Clinical Protocols; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007858:Learning; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000188:drug therapy; D010880:Piperidines / Q000008:administration & dosage / Q000009:adverse effects; D011446:Prospective Studies; D000077208:Remifentanil; D013514:Surgical Procedures, Operative
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid; D018686:Anesthetics, Intravenous; D010880:Piperidines; D000077208:Remifentanil