Comparison of Remifentanil and Low-Dose Fentanyl for Fast-Track Cardiac Anesthesia: A Prospective Randomized Study

Authors

  • Boris Khanykin
  • Rizwan Siddiqi
  • Per F. Jensen
  • Dennis R. Bigler
  • Gennady V. Atroshchenko

DOI:

https://doi.org/10.1532/HSF98.2013229

Abstract

Background: Different anesthetic techniques have been used for fast tracking in cardiac anesthesia. Remifentanil, with its unique pharmacokinetic profile, could be an ideal drug for fast tracking. Possible limitations of remifentanil are rapid onset of postoperative pain after discontinuation of the drug infusion, which may increase the risk of an ischemic event. We conducted this randomized study to compare the efficacy of remifentanil versus low doses of fentanyl in fast-track cardiac anesthesia. It has been hypothesized that remifentanil would provide a safe anesthesia with no impact on myocardial function and with positive effects on extubation time and mobilization.

Methods: We compared the postoperative course of patients, the remifentanil group (RG) and the low-dose fentanyl group (LDFG), in whom remifentanil and low-dose fentanyl, respectively, were used for fast-track cardiac anesthesia. The study was designed as a prospective randomized study. The primary outcomes were changes in the cardiac index and creatine kinase MB fraction (CKMB), extubation times, mobilization times, and lengths of stay in the intensive care unit (ICU) and the hospital. Frequency of myocardial infarction (MI), reoperations due to excessive bleeding, renal impairment, and cerebral complications were registered as well.

Results: Seventy-one patients were enrolled in the study, and 7 were excluded due to difficult airway, bleeding, and technical difficulties. The RG comprised 33 patients and the LDFG comprised of 31 patients. There were no differences between the groups in terms of age, Euroscore, types of surgery, extracorporeal circulation, and aortic cross-clamp time. We did not find significant difference in cardiac index, CKMB, extubation times, mobilization times, length of stay in the ICU and in the hospital between the groups. Postoperative complications such as MI, rates of reoperations, renal and cerebral complications and incidence of atrial fibrillation did not show any significant differences.

Conclusions: Remifentanil fast-track anesthesia for cardiac patients has no negative impact on myocardial function. Both remifentanil and low-dose fentanyl are equally effective and safe for fast-track cardiac anesthesia. The study did not highlight any statistical superiority of remifentanil anesthesia over low-dose fentanyl anesthesia.

References

Bell J, Sartain J, Wilkinson GA, Sherry KM. 1994. Propofol and fentanyl anesthesia for patients with low cardiac output state undergoing cardiac surgery: comparison with high-dose fentanyl anesthesia. Br J Anaesth 73:162-6.nBurkhart CS, Dell-Kuster S, Gamberini M, et al. 2010. Modifiable and nonmodifiable risk factors for postoperative delirium after cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 24:555-9.nEnder J, Borger MA, Scholz M, et all. 2008. Cardiac surgery fast-track treatment in postanesthetic care unit: six-month results of the Leipzig fast-track concept. Anesthesiology 109:61-6.nKomatsu R, Turan AM, Orhan-Sungur M, McGuire J, Radke OC, Apfel CC. 2007. Remifentanil for general anesthesia: a systematic review. Anesthesia 62:1266-80.nLison S, Schill M, Conzen P. 2007. Fast-track cardiac anesthesia: efficacy and safety of remifentanil versus sufentanil. J Cardiothorac Vasc Anesth 21:35-40.nMyles PS, Hunt JO, Fletcher H, et all. 2002. Remifentanil, fentanyl, and cardiac surgery: a double-blinded, randomized, controlled trial of costs and outcomes. Anesth Analg 95:805-12.nPanzer O, Moitra V, Sladen RN. 2009. Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics and the role of peripheral mu antagonists. Crit Care Clin 25:451-69.nSilbert BS, Myles PS. 2009. Is fast-track cardiac anesthesia now the global standard of care? Anesth Analg 108:689-91.nSullivan BL. 2012. Con: early extubation in the operating room following cardiac surgery. Semin Cardiothorac Vasc Anesth 16:187-9.nSvircevic V, Nierich AP, Moons KGM, Brandon Bravo Bruinsma GJ, Kalkman CJ, van Dijk D. 2009. Fast-track anesthesia and cardiac surgery: a retrospective cohort study of 7989 patients. Anesth Analg 108:727-33.nvon Dossow V, Luetz A, Haas A, et al. 2008. Effects of remifentanil and fentanyl on the cell-mediated immune response in patients undergoing elective coronary artery bypass graft surgery. J Int Med Res 36:1235-47.nWeale NK, Rogers CA, Cooper R, Nolan J, Wolf AR. 2004. Effect of remifentanil infusion rate on stress response to the pre-bypass phase of paediatric cardiac surgery. Br J Anaesth 92:187-94.nWinterhalter M, Brandl K, Rahe-Meyer N, et al. 2008. Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl. Eur J Anesthesiol 25:326-35.nZhu F, Lee A, Chee YE. 2012. Fast-track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev 10:CD003587.n

Published

2013-12-26

How to Cite

Khanykin, B., Siddiqi, R., Jensen, P. F., Bigler, D. R., & Atroshchenko, G. V. (2013). Comparison of Remifentanil and Low-Dose Fentanyl for Fast-Track Cardiac Anesthesia: A Prospective Randomized Study. The Heart Surgery Forum, 16(6), E324-E328. https://doi.org/10.1532/HSF98.2013229

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