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CARDIOVASCULAR ANESTHESIA

Remifentanil, Fentanyl, and Cardiac Surgery: A Double-Blinded, Randomized, Controlled Trial of Costs and Outcomes

Paul S. Myles, MB.BS, MPH, MD, FCARCSI, FANZCA^*, Jennifer O. Hunt, RN^*, Helen Fletcher, RN^*, Jennifer Watts, RN Bbus, PGradDip.Hlth.Eco, MCom(EC), David Bain, MB.BS, FANZCA^*, Andrew Silvers, MB.BS, FANZCA^*, and Mark R. Buckland, MB.BS, FANZCA^*

*Department of Anaesthesia & Pain Management, Alfred Hospital; and Departments of Anaesthesia and Epidemiology & Preventive Medicine and the Centre for Health Program Evaluation, Monash University, Clayton, Victoria, Australia

Address correspondence and reprint requests to A/Prof. Paul S. Myles, Department of Anaesthesia & Pain Management, Alfred Hospital, Commercial Road, Prahran, Victoria, 3181 Australia. Address e-mail to p.myles{at}alfred.org.au

Remifentanil may be beneficial in patients undergoing coronary artery bypass graft surgery, by promoting hemodynamic stability, reducing drug requirements, and attenuating the neurohumoral "stress response." We enrolled 77 cardiac surgical patients in a double-blinded, randomized trial and randomly allocated them to one of three groups: remifentanil infusion at 0.83 µg · kg^-1 · min^-1 (Group R); fentanyl bolus, small dose, at 12 µg/kg (Group FLD); and fentanyl bolus, moderate dose, at 24 µg/kg (Group FMD). We found a significant difference in the median time to tracheal extubation: Group FLD, 6.5 h; Group R, 7.3 h; and Group FMD, 9.7 h (P = 0.025). Group R patients had similar times to those of Groups FLD (P = 0.14) and FMD (P = 0.30). Group FLD patients had a longer length of hospital stay (P = 0.030). Patients in Group R had a significantly infrequent rate of hypertension but a frequent rate of hypotension (P < 0.01). The urinary cortisol excretion was larger in Group FLD patients (P < 0.0005), and urine flow was smaller (P < 0.0005). Remifentanil was associated with a propofol dose reduction (P = 0.0005) and a concomitant higher bispectral index (P = 0.032). Three Group FLD patients, but none in groups FMD and R, had postoperative myocardial infarctions (P = 0.032). Remifentanil has larger drug acquisition costs but does not increase the total hospital costs associated with cardiac surgery.

IMPLICATIONS: Remifentanil did not significantly reduce the duration of tracheal intubation after cardiac surgery. Remifentanil, when compared with fentanyl (total doses of approximately 15 and 28 µg/kg), blunts the hypertensive responses associated with cardiac surgery but is associated with more hypotension; when compared with fentanyl 15 µg/kg, remifentanil reduces cortisol excretion. Larger-dose opioids (remifentanil 0.85 µg · kg^-1 · min^-1 or fentanyl 28 µg/kg) were associated with a decreased rate of myocardial infarction after cardiac surgery.

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