BJA Advance Access published online on April 10, 2007
British Journal of Anaesthesia, doi:10.1093/bja/aem069
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Low-dose remifentanil to suppress haemodynamic responses to noxious stimuli in cardiac surgery: a dose-finding study
Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, University Hospital Vienna, Vienna, Austria
* Corresponding author: Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, University Hospital Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria. E-mail: barbara.steinlechner{at}meduniwien.ac.at
Background: High-dose remifentanil (1–5 µg kg–1 min–1), commonly used for cardiac surgery, has been associated with muscle rigidity, hypotension, bradycardia, and reduced cardiac output. The aim of this study was to determine an optimal lower remifentanil dose, which should be accompanied by fewer adverse events, that still effectively suppresses haemodynamic responses to typical stressful stimuli (i.e. intubation, skin incision, and sternotomy).
Methods: Total i.v. anaesthesia consisted of a target-controlled propofol (2 µg ml–1) and a remifentanil infusion. Forty patients were allocated to receive either a constant infusion of remifentanil at 0.1 µg kg–1 min–1 or up-titrations to 0.2, 0.3, or 0.4 µg kg–1 min–1, respectively, 5 min before each stimulus. Subsequently, changes in heart rate and mean arterial blood pressure were recorded for 8 min. Increases exceeding 20% of baseline were considered to be of clinical relevance. Patients who exhibited these alterations were termed responders.
Results: The number of responders was less with the two higher remifentanil dosages (P < 0.05) while propofol target doses could either be kept at the same level or even be reduced without affecting the plane of anaesthesia. Although single phenylephrine bolus had to be applied more frequently in these two groups (P < 0.05), no severe haemodynamic depression was observed.
Conclusions: Remifentanil at 0.3 and 0.4 µg kg–1 min–1 in combination with a target-controlled propofol infusion in the pre-bypass period is well tolerated. It appears to mitigate potentially hazardous haemodynamic responses from stressful stimuli equally well as higher doses when compared with data from the literature.
Keywords: anaesthetic techniques, i.v. infusion; analgesics opioid, remifentanil; cardiovascular anaesthesia; monitoring, bispectral index; stress
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