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NEUROSURGICAL ANESTHESIA

A Comparison of Remifentanil and Fentanyl in Patients Undergoing Surgery for Intracranial Mass Lesions

Guruswamy Balakrishnan, MD^*, Peter Raudzens, MD, Satwant K. Samra, MD, Kenneth Song, MD^§, Jean A. Boening, MD^||, Voytek Bosek, MD^¶, Brenda D. Jamerson, PharmD^#, and David S. Warner, MD^**

*Henry Ford Hospital, Detroit Michigan; St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, Arizona; University of Michigan, Ann Arbor, Michigan; §University of Texas Southwestern, Dallas, Texas; ||Abbott-Northwestern Hospital, Minneapolis, Minnesota; ¶University of South Florida, Moffitt Cancer Center, Tampa, Florida; #Glaxo Welcome, Research Triangle Park, North Carolina; and **Duke University Medical Center, Durham, North Carolina

Address correspondence and reprint requests to David S. Warner, MD, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710. Address e-mail to warne002{at}mc.duke.edu

We compared the effects of remifentanil versus fentanyl during surgery for intracranial space-occupying lesions. Patients were randomly assigned to receive either remifentanil (0.5 µg · kg^-1 · min^-1 IV during the induction of anesthesia reduced to 0.25 µg · kg^-1 · min^-1 after endotracheal intubation; n = 49) or fentanyl (dose per usual practice of the anesthesiologist; n = 54). Anesthesia maintenance doses of isoflurane, nitrous oxide, and opioid were at the anesthesiologist’s discretion for both groups. There were no differences between opioid groups for the frequency of responses (hemodynamic, movement, and tearing) to intubation, pinhead holder placement, skin incision, or closure of the surgical wound. Adverse event frequencies were similar between groups. Times to follow verbal commands (P < 0.001) and tracheal extubation (P = 0.04) were more rapid for remifentanil. The percentage of patients with a normal recovery score (were alert or arousable to quiet voice, were oriented, were able to follow commands, had motor function unchanged from their preoperative evaluation, were not agitated, and had modified Aldrete Scores of 9–10) at 10 min after surgery was more for remifentanil (45% vs 18%; P = 0.005). By 20 min, no difference between groups existed (P = 0.27). Anesthesiologists used more isoflurane in the fentanyl group (4.22 vs 1.93 minimum alveolar anesthetic concentration hours). Neurosurgeons, blinded to treatment group, favored the use of remifentanil. Similar frequencies of light anesthesia responses and other adverse events suggest that intraoperative depths of anesthesia were similar in the two groups. Under these conditions, emergence was more rapid with remifentanil. This is consistent with the necessity for less isoflurane use in the remifentanil group and the intrinsic rapid clearance of this opioid.

Implications: Patients given remifentanil-based anesthesia for craniotomy had faster recovery times from anesthesia than did those given fentanyl-based anesthesia.

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