Comparison of the effects of remifentanil or fentanyl on anaesthetic induction characteristics of propofol, thiopental or etomidate

Predictive model for post-induction hypotension in patients undergoing transcatheter aortic valve implantation: a retrospective observational study

PURPOSE

Post-induction hypotension (PIH) is an independent risk factor for prolonged postoperative stay and hospital death. Patients undergoing transcatheter aortic valve implantation (TAVI) are prone to develop PIH. This study aimed to develop a predictive model for PIH in patients undergoing TAVI.

METHODS

This single-center retrospective observational study included 163 patients who underwent TAVI. PIH was defined as at least one measurement of systolic arterial pressure <90 mmHg or at least one incident of norepinephrine infusion at a rate >6 µg/min from anesthetic induction until 20 min post-induction. Multivariate logistic regression analysis was performed to develop a predictive model for PIH in patients undergoing TAVI.

RESULTS

In total, 161 patients were analyzed. The prevalence of PIH was 57.8%. Multivariable logistic regression analysis showed that baseline mean arterial pressure ≥90 mmHg [adjusted odds ratio (aOR): 0.413, 95% confidence interval (95% CI): 0.193-0.887; p=0.023] and higher doses of fentanyl (per 1-µg/kg increase, aOR: 0.619, 95% CI: 0.418-0.915; p=0.016) and ketamine (per 1-mg/kg increase, aOR: 0.163, 95% CI: 0.062-0.430; p=0.002) for induction were significantly associated with lower risk of PIH. A higher dose of propofol (per 1-mg/kg increase, aOR: 3.240, 95% CI: 1.320-7.920; p=0.010) for induction was significantly associated with higher risk of PIH. The area under the curve (AUC) for this model was 0.802.

CONCLUSION

The present study developed predictive models for PIH in patients who underwent TAVI. This model may be helpful for anesthesiologists in preventing PIH in patients undergoing TAVI.

Improved haemodynamic stability and cerebral tissue oxygenation after induction of anaesthesia with sufentanil compared to remifentanil: a randomised controlled trial

BACKGROUND

Balanced anaesthesia with propofol and remifentanil, compared to sufentanil, often decreases mean arterial pressure (MAP), heart rate (HR) and cardiac index (CI), raising concerns on tissue-oxygenation. This distinct haemodynamic suppression might be attenuated by atropine. This double blinded RCT, investigates if induction with propofol-sufentanil results in higher CI and tissue-oxygenation than with propofol-remifentanil and if atropine has more pronounced beneficial effects on CI and tissue-oxygenation in a remifentanil-based anaesthesia.

METHODS

In seventy patients scheduled for coronary bypass grafting (CABG), anaesthesia was induced and maintained with propofol target controlled infusion (TCI) with a target effect-site concentration (Cet) of 2.0 μg ml- 1 and either sufentanil (TCI Cet 0.48 ng ml- 1) or remifentanil (TCI Cet 8 ng ml- 1). If HR dropped below 60 bpm, methylatropine (1 mg) was administered intravenously. Relative changes (∆) in MAP, HR, stroke volume (SV), CI and cerebral (SctO2) and peripheral (SptO2) tissue-oxygenation during induction of anaesthesia and after atropine administration were analysed.

RESULTS

The sufentanil group compared to the remifentanil group showed significantly less decrease in MAP (∆ = - 23 ± 13 vs. -36 ± 13 mmHg), HR (∆ = - 5 ± 7 vs. -10 ± 10 bpm), SV (∆ = - 23 ± 18 vs. -35 ± 19 ml) and CI (∆ = - 0.8 (- 1.5 to - 0.5) vs. -1.5 (- 2.0 to - 1.1) l min- 1 m- 2), while SctO2 (∆ = 9 ± 5 vs. 6 ± 4%) showed more increase with no difference in ∆SptO2 (∆ = 8 ± 7 vs. 8 ± 8%). Atropine caused higher ∆HR (13 (9 to 19) vs. 10 ± 6 bpm) and ∆CI (0.4 ± 0.4 vs. 0.2 ± 0.3 l min- 1 m- 2) in sufentanil vs. remifentanil-based anaesthesia, with no difference in ∆MAP, ∆SV and ∆SctO2 and ∆SptO2.

CONCLUSION

Induction of anaesthesia with propofol and sufentanil results in improved haemodynamic stability and higher SctO2 compared to propofol and remifentanil in patients having CABG. Administration of atropine might be useful to counteract or prevent the haemodynamic suppression associated with these opioids.

TRIAL REGISTRATION

Clinicaltrials.gov on June 7, 2013 (trial ID: NCT01871935 ).

Comparison of Fentanyl, Remifentanil, Sufentanil and Alfentanil in Combination with Propofol for General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Opioid analgesics are commonly used along with propofol during general anesthesia. Due to the dearth of data on the quality of anesthesia achieved with this combination, the present meta-analysis was carried out.

METHODS

Electronic databases were searched for appropriate studies using a suitable search strategy. Randomized clinical trials comparing the combination of remifentanil/sufentanil/alfentanil with propofol with fentanyl and propofol, were included. The outcome measures were as follows: total propofol dose to achieve the desired general anesthesia; time of onset and duration of general anesthesia; depth of general anesthesia; and recovery time (time for eye-opening and time taken for extubation). Risk of bias was assessed and Forest plots were generated for eligible outcomes. The weighted mean difference [95% confidence intervals] was used as the effect estimate.

RESULTS

Fourteen studies were included in the systematic review and 13 were included in the metaanalysis. Statistically significant differences were observed for remifentanil in comparison to fentanyl when combined with propofol: Propofol dose (in mg) -76.18 [-94.72, -57.64]; time of onset of anesthesia (min) -0.44 [-0.74, -0.15]; time taken for eye-opening (min) -3.95 [-4.8, -3.1]; and time for extubation (min) -3.53 [-4.37, -2.7]. No significant differences were observed for either sufentanil or alfentanil about the dose of propofol required and due to scanty data, pooling of the data could not be attempted for other outcome measures for either sufentanil or alfentanil.

CONCLUSION

To conclude, we found that remifentanil has a statistically significant anesthetic profile than fentanyl when combined with propofol. Scanty evidence for both alfentanil and sufentanil precludes any such confirmation.

Etomidate-remifentanil is more suitable for monitored anesthesia care during gastroscopy in older patients than propofol-remifentanil

Background

This prospective and randomized study was designed to compare safety, potential complications, and patient and examiner satisfaction of 2 anesthetic combinations – etomidate-remifentanil and propofol-remifentanil – in elderly patients undergoing diagnostic gastroscopy.

Material/Methods

A group of 720 patients, aged 60–80 years, scheduled for diagnostic gastroscopy under sedation were prospectively randomized. After 0.4–0.6 μg kg⁻¹ of remifentanil was infused, etomidate or propofol was administered. Patients in the etomidate group received doses of etomidate at 0.1–0.15 mg kg⁻¹ followed by 4–6 mg. Patients in the propofol group received doses of propofol at 1–2 mg kg⁻¹ followed by 20–40 mg. Physiological indexes were evaluated for the 715 of 720 patients that completed the treatment. The onset time, duration time, and discharge time were recorded. Physicians, anesthetists, and patients were surveyed to assess their satisfaction.

Results

Systolic pressure and diastolic pressure decreased significantly after the procedure in the propofol group (P<0.001). The average heart rate was significantly lower in the propofol group (P<0.05). No periods of desaturation (SpO₂ <95%) were observed in either group. The onset time was earlier in the etomidate group (P=0.00). All adverse events, with the exception of myoclonus, were greater in the propofol group, and physician and patient satisfaction in both groups was similar.

Conclusions

Etomidate-remifentanil administration for sedation and analgesia during gastroscopy resulted in more stable hemodynamic responses and less adverse events in older patients.

Use of remifentanil and alfentanil in endotracheal intubation: a comparative study

Background:

Opioids, such as alfentanil, are used to facilitate endotracheal intubation without the use of neuromuscular blocking agents in patients undergoing elective surgery.

Objectives:

The goal of this study was to evaluate the endotracheal intubation conditions when remifentanil or alfentanil was used with propofol without the application of neuromuscular blocking agents.

Patients and Methods:

One hundred American Society of Anesthesiologists (ASA) grade I patients scheduled for elective surgery were enrolled in this prospective, randomized, triple-blinded study. The patients were randomized to group A (alfentanil) or R (remifentanil). In group A, alfentanil (50 mcg/kg) was intravenously injected over 10 seconds, and after 45 seconds or at the occurrence of apnea, propofol (2 mg/kg) was intravenously injected over 5 seconds. Thirty seconds after the administration of propofol, laryngoscopy and endotracheal intubation were attempted. In group R, remifentanil (5 mcg/kg) was administered instead of alfentanil. Intubation conditions, including ease of laryngoscopy, patency of the vocal cords, jaw relaxation, limb movement (1-4 score), and also, demographic data were evaluated.

Results:

There were no demographic data differences between groups (age, weight, and sex). Further, laryngoscopy, jaw relaxation, and limb movement scores were similar in the R and A groups and there were no significant differences, but vocal cords were significantly more patent in group R than those in group A (P = 0. 028).

Conclusions:

The results of this study showed that remifentanil, similar to alfentanil, provided excellent conditions for endotracheal intubation when used with propofol for the induction of anesthesia; however, remifentanil improved the patency of the vocal cords to a greater extent than alfentanil.

Remifentanil and etomidate for laryngeal mask airway insertion

Etomidate does not depress the upper airway reflexes, making it difficult to insert a laryngeal mask airway (LMA) when using it for anaesthesia. This study investigated the effect of adding remifentanil to etomidate for LMA insertion. Fifty adult patients, undergoing cystoscopy, were randomized to two groups. The propofol-remifentanil group (n=25) received propofol anaesthesia induction (2.5 mg/kg) and a remifentanil bolus of 0.5 microg/kg, followed by a 2-min remifentanil infusion of 0.05 microg/kg per min. The etomidate-remifentanil group (n=25) received etomidate anaesthesia induction (0.3 mg/kg) and remifentanil as described. The LMA was inserted by a blinded anaesthetist who assessed a number of parameters. Only 13 LMAs were inserted at the first attempt in the etomidate-remifentanil group compared with 23 in the propofol-remifentanil group. Gagging, chest rigidity and myoclonus occurred significantly more frequently in the etomidate-remifentanil group. We conclude that the addition of remifentanil to etomidate anaesthesia induction does not improve LMA insertion.

Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Controlled hypotension is used to improve surgical conditions during microscopic and endoscopic sinus surgery. New short-acting anesthetics such as propofol and remifentanil allow exact control of intraoperative blood pressure and thus might be valuable tools to improve intraoperative conditions for the otorhinolaryngological surgeon. Intravenous anesthesia was compared with traditional balanced anesthesia by subjective assessment of surgical conditions made by two experienced otorhinolaryngological surgeons.

STUDY DESIGN

Prospective, randomized, patient- and observer-blinded study.

METHODS

Ninety consecutive patients were randomly assigned to receive intravenous anesthesia with propofol 5 to 8 mg.kg-1.h-1 and remifentanil 10 to 30 microg.kg-1.h-1 or with isoflurane (0.4-1.0 vol%) and repetitive doses of 0.5 to 1 mg alfentanil. An injectable vasodilator was used in both groups to keep mean arterial pressure between 60 and 70 mm Hg (8-9.3 hecto-pascal). The attending otorhinolaryngological surgeon was unaware of the type of anesthesia administered. Immediately after the operation the surgeons rated surgical conditions (bleeding from the surgical field) on a visual analogue scale (0-10 cm) and on a verbal rating scale.

RESULTS

Blood pressure was not different between the two groups, but heart rate was lower in the intravenous anesthesia group (mean heart rate in the intravenous anesthesia group, 62 beats per min [95% confidence interval, 52-72]; mean heart rate in the balanced anesthesia group, 75 beats per min [95% confidence interval, 67-83]). Surgical conditions were rated to be significantly better (P <.0001) during anesthesia with propofol-remifentanil (median rating: 2.8; 25th/75th percentile: 2.0/3.4) compared with isoflurane-alfentanil (median rating: 4.9; 25th/75th percentile: 3.6/7.6).

CONCLUSIONS

Intravenous anesthesia using propofol-remifentanil provides better surgical conditions compared with a traditional balanced anesthesia technique using isoflurane-alfentanil. It is hypothesized that lower cardiac output caused by decreased heart rate during deep general anesthesia is responsible for this result.