A randomised controlled trial comparing remifentanil and fentanyl for induction of anaesthesia in CABG surgery

Considerations for the use of short-acting opioids in general anesthesia

Anesthesiologists play a critical role in facilitating a positive perioperative experience and early recovery for patients. Depending on the kind of procedure or surgery, a wide variety of agents and techniques are currently available to anesthesiologists to administer safe and efficacious anesthesia. Notably, the fast-track or ambulatory surgery environment requires the use of agents that enable rapid induction, maintenance, and emergence combined with minimal adverse effects. Short-acting opioids demonstrate a safe and rapid onset/offset of effect; that short effect is both predictable and precise. It also ensures easier titration and reduced or rapidly reversed side effects. Due to their distinct pharmacokinetic and pharmacodynamic properties, and, in one case, rapid extra-hepatic clearance of remifentanil, these agents have several applications in general anesthesia.

Remifentanil in cardiac surgery: a meta-analysis of randomized controlled trials

OBJECTIVE

The authors conducted a review of randomized controlled trials to identify advantages in clinically relevant outcomes in patients undergoing cardiac surgery with remifentanil.

DESIGN

Meta-analysis.

SETTING

Hospitals.

PARTICIPANTS

A total of 1,473 patients from 16 randomized trials.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULT

PubMed, BioMedCentral, and conference proceedings were searched (updated May 2010) for randomized trials that compared remifentanil with fentanyl or sufentanil in cardiac anesthesia. Four independent reviewers performed data extraction, with divergences resolved by consensus. Overall analysis showed that the use of remifentanil was associated with a significant reduction in postoperative mechanical ventilation (WMD = -139 min [-244, -32], p for effect = 0.01, p for heterogeneity < 0.001, I(2) = 89%); length of hospital stay (WMD = -1.08 days [-1.60, -0.57], p for effect < 0.0001, p for heterogeneity = 0.004, I(2) = 71%); and cardiac troponin-I release (WMD = -2.08 ng/mL [-3.93, -0.24], p for effect = 0.03, p for heterogeneity < 0.02, I(2) = 74%). No difference was noted in mortality (3/344 [0.87%] in the remifentanil group vs [1.06%] the control group, OR 0.76 [0.17-3.38], p for effect = 0.72, p for heterogeneity = 0.35, I(2) = 5%).

CONCLUSIONS

Remifentanil reduces cardiac troponin release, time of mechanical ventilation, and length of hospital stay in patients undergoing cardiac surgery.

Remifentanil for general anaesthesia: a systematic review

We performed a quantitative systematic review of randomised, controlled trials that compared remifentanil to short-acting opioids (fentanyl, alfentanil, or sufentanil) for general anaesthesia. Eighty-five trials were identified and these included a total of 13 057 patients. Intra-operatively, remifentanil was associated with clinical signs of deeper analgesia and anaesthesia, such as fewer responses to noxious stimuli (relative risk 0.65, 95% CI 0.48-0.87), more frequent episodes of bradycardia (1.46, 1.04-2.05), more hypotension (1.68, 1.36-2.07) and less hypertension (0.60, 0.46-0.78). Postoperatively, remifentanil was associated with faster recovery (difference in extubation time of -2.03, 9.5% CI, -2.92 to -1.14 min), more frequent postoperative analgesic requirements (1.36, 1.21-1.53) and fewer respiratory events requiring naloxone (0.25, 0.14-0.47). Remifentanil had no overall impact on postoperative nausea (1.03, 0.97-1.09) or vomiting (1.06, 0.96-1.17), but was associated with twice as much shivering (2.15, 1.73-2.69). Remifentanil does not seem to offer any advantage for lengthy, major interventions, but may be useful for selected patients, e.g. when postoperative respiratory depression is a concern.