Comparative efficacy and safety of remifentanil and fentanyl in ‘fast track’ coronary artery bypass graft surgery: a randomized, double-blind study

Abstract

This multi-centre, parallel group, randomized, double-blind study compared the efficacy and safety of high-dose remifentanil administered by continuous infusion with an intermittent bolus fentanyl regimen, when given in combination with propofol for general anaesthesia in 321 patients undergoing elective coronary artery bypass graft surgery. A significantly lower proportion of the patients who received remifentanil had responses to maximal sternal spread (the primary efficacy endpoint) compared with those who received fentanyl (11% vs 52%; P<0.001). More patients who received remifentanil responded to tracheal intubation compared with those who received fentanyl (24% vs 9%; P<0.001). However, fewer patients who received remifentanil responded to sternal skin incision (11% vs 36%; P<0.001) and sternotomy (14% vs 60%; P <0.001). Median time to extubation was longer in the subjects who received remifentanil than for those who received fentanyl (5.1 vs 4.2 h; P=0.006). There were no statistically significant differences between the two groups in the times for transfer from intensive care unit or hospital discharge but time to extubation was significantly longer in the remifentanil group. Overall, the incidence of adverse events was similar but greater in the remifentanil group with respect to shivering (P<0.049) and hypertension (P<0.001). Significantly more drug-related adverse events were reported in the remifentanil group (P=0.016). There were no drug-related adverse cardiac outcomes and no deaths from cardiac causes before hospital discharge in either treatment group.

Remifentanil for general anaesthesia: a systematic review

“…We were able to retrieve 220 articles, 104 of which met the inclusion criteria [6][7][8][9][10][11][12][13][14][15][16][17][18][19]. We eliminated 116 of the retrieved studies for the following reasons: two were review articles, 10 did not compare remifentanil with other opioids, nine were not randomised trials, 37 did not have relevant data or had data that could not be extrapolated from the published graphs, five did not mention the number of patients per group, 11 did not use general anaesthesia, 10 included data from children (age less than 18 years) and 20 used different anaesthetics in the remifentanil and comparator group.…”

“…However, we included studies in which rigid bronchoscopy or laryngoscopy was conducted under general anaesthesia without intubation. If remifentanil use extended into the postoperative period, we only extracted the intra-operative data [11][12][13][14][15][16][17][18][19]. Reports were excluded if remifentanil was used for sedation and analgesia for patients in the intensive care unit.…”

Fast-Track Cardiac Anaesthesia at a Tertiary Care Cardiac Centre in Nepal

“…We have included combination of low dose propofol, ketamine, midazolam as induction agent, fentanyl as opioid and vecuronium as muscle relaxant. The most common induction agent is propofol in combination with an opioid, usually at a dose of 0.5 mg/kg with 10mg boluses until loss of consciousness 17,21,22,23,24 although some use propofol in higher doses 2,5,25 or even start directly with an infusion. 26 Etomidate, thiopentone and ketamine are described as being used.…”

“…He also showed a significantly decreased time to extubation with no increase in the incidence of ischaemia or postoperative myocardial infarction. Since then propofol has been used commonly in cardiac anaesthesia, either as part of a total intravenous anaesthetic technique 5,23,28 or as sedation on CPB and continuing into the ICU. 2,5,17,22,24,25,26 The most common agent used for sedation of these patients post bypass and into the ICU is propofol.…”

“…2,5,17,22,24,25,26 The most common agent used for sedation of these patients post bypass and into the ICU is propofol. 5,17,21,22,23,24,26 Some authors add midazolam either as boluses or an infusion. 5 We have continued with propofol infusion.…”