Remifentanil with morphine transitional analgesia shortens neurological recovery
compared to fentanyl for supratentorial craniotomy.
Author(s): Gelb AW, Salevsky F, Chung F, Ringaert K, McTaggart-Cowan RM, Wong T, Manninen
PH.
Affiliation(s): Department of Anaesthesia, London Health Sciences Centre, London, Ontario,
Canada. agelb@uwo.ca
Publication date & source: 2003, Can J Anaesth. , 50(9):946-52
PURPOSE: To compare the recovery profiles, efficacy and safety of remifentanil
and morphine for transitional analgesia with fentanyl in patients undergoing
elective craniotomy for supratentorial mass lesions.
METHODS: Ninety-one patients were enrolled in this prospective, randomized,
multicentre study. Anesthesia was induced with thiopental and remifentanil (1.0
micro g x kg(-1) bolus and a 1 micro g x kg(-1) x min(-1) infusion) or fentanyl
(1 micro g x kg(-1) bolus and a 1.0 micro g x kg(-1) x min(-1) infusion). The
opioid infusion continued until the level of anesthesia was deemed appropriate
for intubation. Anesthesia was maintained with N(2)O/O(2), isoflurane 0.5 MAC and
remifentanil 0.2 micro g x kg(-1) x min(-1) or fentanyl 0.04 micro g x kg(-1) x
min(-1). At bone flap replacement, either morphine 0.08 mg x kg(-1) (remifentanil
group) or saline (fentanyl group) was given.
RESULTS: Systolic blood pressure was greater in those receiving fentanyl during
induction (145.6 +/-17.5 mmHg vs 128.8 +/-18.3 mmHg; P = 0.006) and intubation
(126.9 +/-17.1 vs 110.9 +/-16.5 mmHg; P < 0.001). Median time to tracheal
extubation was similar but less variable in the remifentanil group (remifentanil
= 8 min: range = 2-44 min; fentanyl = 8 min: range = 1-732 min). The fentanyl
patients required a longer time to achieve the first normal neurological score
(fentanyl = 38.0 min; remifentanil = 26.0 min; P = 0.035). Both the
anesthesiologists and the recovery room nurses rated remifentanil better with
respect to level of consciousness. Analgesics were required earlier in patients
receiving remifentanil; median time 0.5 vs 1.08 hr, P < 0.001.
CONCLUSIONS: Remifentanil is a suitable alternative to fentanyl in supratentorial
craniotomy. Time to preoperative neurological recovery is faster and morphine
provides some transitional analgesia without compromising the quality of
recovery.
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