Anesthesiology Pain Medicine
Anesthesiology Pain Medicine
Anesthesiology Pain Medicine
6884
Anesthesiology
KOWSAR Pain Medicine
www.AnesthPain.com
A R T IC LE I NFO A B S T RAC T
Article type: Background: Intravenous opioids are administered to prevent and control hemody-
Original Article namic changes due to endotracheal intubation. Except for special cases such as preec-
lampsia, these drugs are not recommended for parturants candidate for cesarean sec-
Article history: tion because of the respiratory depression caused in the newborn.
Received: 20 Jun 2012 Objectives: According to rapid metabolism of remifentanil, the current study aimed to
Revised: 05 Jul 2012 compare hemodynamic changes in preeclamptic parturants who received remifentanil
Accepted: 25 Jul 2012 and fentanyl for cesarean section under general anesthesia.
Patients and Methods: This single blind randomized clinical trial was performed on
Keywords: preeclamptic pregnant women candidate for cesarean section under general anesthesia.
Cesarean Section They were divided into two groups. In the first group 0.05 g/kg/min remifentanil was
Pre-Eclampsia infused for 3 minutes before induction of anesthesia and in the second group 1ml (50 g)
Intubation, Intratracheal fentanyl was injected before induction. Heart rate (HR), systolic blood pressure (SBP) and
Fentanyl diastolic blood pressure (DBP) before and after intubation and also Apgar index were
Remifentanil measured and compared between the two groups.
Results: All hemodynamic variables increased after intubation in the fentanyl group
(pSBP = 0.146, pDBP = 0.019, pHR < 0.001). Additionally, decrease in SBP (P = 0.018) and
DBP (P = 0.955) and mild increase in HR (P = 0.069) after intubation in the remifentanil
group was observed. No significant difference was found between Apgar indexes of the
two groups (P = 0.771).
Conclusions: It can be postulated that remifentanil can be used in partituents candidate
for cesarean delivery under general anesthesia to prevent severe increase in blood pres-
sure and heart rate during tracheal intubation without adverse effects on newborn.
Published by Kowsar Corp, 2012. cc 3.0.
* Corresponding author: Alireza Pournajafian, Department of Anesthesiology, Firoozgar Hospital, Beh Afarin St., Karim Khan Blvd. Tehran, IR Iran. Tel: +98-
2188946762, Fax: +98-2188942622, E-mail: [email protected]
DOI: 10.5812/aapm.6884
2012 Iranian Society of Regional Anesthesia and Pain Medicine; Published by Kowsar Corp.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Remifentanil, Fentanyl: Hemodynamic Markers in Preeclamptic Parturient Pournajafian A et al.
Anesth Pain.2012;2(2) 91
Pournajafian A et al. Remifentanil, Fentanyl: Hemodynamic Markers in Preeclamptic Parturient
ence (P < 0.001 and 0.019, respectively). In remifentanil syndrome, coagulopathies and patients refusal of spinal
group, however, apart from HR that increased after ETI, anesthesia (15, 16). In such cases, however, hemodynamic
SBP and DBP decreased but only differences of the SBP responses to ETI are unavoidable. Because of transient de-
was significant (P = 0.018). This suggests the priority of layed respiratory depression with higher doses of remi-
remifentanil over fentanyl in the patients. Table 2 indi- fentanil was noted in some newborns (17-20), in the cur-
cates that there was no significant difference between rent study safe dose of this drug that had been previously
mean Apgar indexes of neonates in the two groups. The used in labor, was considered. Opioids was also used in
minimum Apgar recorded in both group was 7. The num- epidural space in pregnant women for cesarean section
ber of neonates with apgar score 7, 8, 9, 10 in remifentanil without significant difference in maternal complications
group were 1, 6, 9, 4 and in Fentanyl group were 1, 7, 7, 3 and Apgar scores (21). Safavi M et al. showed that some
respectively. No newborn in both groups needed tracheal drugs such as Nitroglycerin are effective in attenuating
intubation or ventilatory support. the pressor response to tracheal intubation in severe
preeclampsia and could be used instead of opioids to
Table 2. Comparison Between Remifentanil and Fentanyl Groups Regard- control hemodynamic responses (22). Remifentanil and
ing Apgar Index in Neonates 1min After delivery
fentanyl were also used effectively in endotracheal intu-
Apgar Index No. (Mean SD) P value bation without use of neuromuscular blocking drugs (23,
Remifentanil group 20 (0.880 0.083) 0.771 24). Remifentanil infusion tends to faster wake up test
Fentanyl group 18 (0.866 0.084) 0.771 than alfentanil in spinal fusion surgeries (25) (because of
rapid metabolism) and is suggested to be used in situa-
5. Discussion tions that require fast effect and rapid recovery of opioid
Remifentanil is known as an ultrashort effect opioid effects. In this regard, it was postulated that remifentanil
which has a half-life of 1.3 minute. This drug has a higher may perform a prominent role because of its stabilizing
clearance rate than liver blood flow and significant extra- impact on heart rate, blood pressure and Apgar index.
hepatic metabolism and trivial pulmonary metabolism Low dose remifentanil can be used safely in parturients
(9). Additionally, its concentration ratio between umbili- candidate for cesarean section without noticeable ad-
cal vein and umbilical artery is 0.88 which does not result verse effects on newborn.
in remarkable fetal exposure due to its rapid metabolism
(10). The current study attempted to compare hemody- Acknowledgments
namic changes in preeclamptic parturients at cesarean We would like to appreciate all anesthesia technicians
delivery after ETI and administration of remifentanil vs. in operating room of Firoozgar hospital who helped us
fentanyl. No severe changes were observed in hemody- in this project.
namic markers of mothers but superiority of remifen-
tanil over fentanyl can be suggested. This is because of Authors Contribution
significant decrease in SBP in remifentanil group vs. sig-
None declared.
nificant increase in HR and DBP in fentanyl group, both
after ETI.
Safety and efficacy of remifentanil have been demon- Financial Disclosure
strated in some case series and randomized controlled None declared.
trials (RCTs) in pregnant women. Roelants et al. used 0.05
g/kg per minute infusion and 25 g bolus of remifentanil Funding/Support
and observed 5 minutes analgesia during normal vaginal
Tehran University of Medical Science.
delivery (11). Moreover, it has been reported by Owen et al.
that 34 hours of remifentanil infusion has no noticeable
References
adverse effect on newborn (12). Furthermore, in the study
1. Shribman AJ, Smith G, Achola KJ. Cardiovascular and catechol-
conducted by Douma et al., superiority of remifentanil
amine responses to laryngoscopy with and without tracheal in-
over fentanyl and meperidine in labor was provided. This tubation. Br J Anaesth. 1987;59(3):295-9.
had reduced the need for regional anesthetic support 2. Cafiero T, Di Minno RM, Di Iorio C. QT interval and QT dispersion
while no change in Apgar index was observed (13). Pala- during the induction of anesthesia and tracheal intubation: a
comparison of remifentanil and fentanyl. Minerva Anestesiol.
cio et al. also showed no negative impact upon neonates 2011;77(2):160-5.
born from parturients with obstetric emergencies when 3. Safavi M, Honarmand A. Attenuation of cardiovascular respons-
remifentanil bolus dose at 1g/kg was administered as es to laryngoscopy and tracheal intubation--intravenous sufent-
anil vs pethidine. Middle East J Anesthesiol. 2008;19(6):1349-59.
maintenance in cesarean sections (14). Although routine-
4. Kazuhiko F. Opioids. In: Miller RD, Eriksson LI, Fleisher LA, Wie-
ly opioids are not drugs of choice in induction of general ner-Kronish JP, Young WL, editors. Anesthesia E-Book: 2-Volume Set:
anesthesia during cesarean section, little amounts of fen- Elsevier Health Sciences; 2009.
tanyl is administered in cases with preeclampsia, HELLP 5. Eisele J, Wright R, Rogge P. Newborn and maternal fentanyl levels
92 Anesth Pain.2012;2(2)
Remifentanil, Fentanyl: Hemodynamic Markers in Preeclamptic Parturient Pournajafian A et al.
at cesarean section. Anesth Analg. 1982;61(2):179. hem K, et al. [Maternal and neonatal effects of remifentanil for
6. Glosten B. Anesthesia for obstetrics. In: Miller RD, al. e, editors. general anaesthesia for Caesarean delivery]. Ann Fr Anesth Rean-
Clinical Anesthesia (5th edition); 2000. im. 2007;26(4):299-304.
7. Richardson SP, Egan TD. The safety of remifentanil by bolus injec- 18. Draisci G, Valente A, Suppa E, Frassanito L, Pinto R, Meo F, et al.
tion. Expert Opin Drug Saf. 2005;4(4):643-51. Remifentanil for cesarean section under general anesthesia: ef-
8. Servin FS, Billard V. Remifentanil and other opioids. Handb Exp fects on maternal stress hormone secretion and neonatal well-
Pharmacol. 2008(182):283-311. being: a randomized trial. Int J Obstet Anesth. 2008;17(2):130-6.
9. Glass PS, Hardman D, Kamiyama Y, Quill TJ, Marton G, Donn KH, 19. Ngan Kee WD, Khaw KS, Ma KC, Wong AS, Lee BB, Ng FF. Maternal
et al. Preliminary pharmacokinetics and pharmacodynamics and neonatal effects of remifentanil at induction of general an-
of an ultra-short-acting opioid: remifentanil (GI87084B). Anesth esthesia for cesarean delivery: a randomized, double-blind, con-
Analg. 1993;77(5):1031-40. trolled trial. Anesthesiology. 2006;104(1):14-20.
10. Kan RE, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP. In- 20. Park BY, Jeong CW, Jang EA, Kim SJ, Jeong ST, Shin MH, et al. Dose-
travenous remifentanil: placental transfer, maternal and neona- related attenuation of cardiovascular responses to tracheal
tal effects. Anesthesiology. 1998;88(6):1467-74. intubation by intravenous remifentanil bolus in severe pre-
11. Roelants F, De Franceschi E, Veyckemans F, Lavandhomme P. eclamptic patients undergoing Caesarean delivery. Br J Anaesth.
Patient-controlled intravenous analgesia using remifentanil in 2011;106(1):82-7.
the parturient. Can J Anaesth. 2001;48(2):175-8. 21. Imani F, Entezari SR, Alebouyeh MR, Parhizgar S. The maternal
12. Owen MD, Poss MJ, Dean LS, Harper MA. Prolonged intrave- and neonatal effects of adding tramadol to 2% lidocaine in epi-
nous remifentanil infusion for labor analgesia. Anesth Analg. dural anesthesia for Cesarean section. Anesth Pain. 2011;1(1):25-9.
2002;94(4):918-9, table of contents. 22. Safavi M, Honarmand A, Azari N. Attenuation of the Pressor Re-
13. Douma MR, Verwey RA, Kam-Endtz CE, van der Linden PD, Stien- sponse to Tracheal Intubation in Severe Preeclampsia: Relative
stra R. Obstetric analgesia: a comparison of patient-controlled Efficacies of Nitroglycerine Infusion, Sublingual Nifedipine, and
meperidine, remifentanil, and fentanyl in labour. Br J Anaesth. Intravenous Hydralazine. Anesth Pain. 2011;1(2):81-9.
2010;104(2):209-15. 23. Hanci V. Tracheal Intubation Without Use of Muscle Relax-
14. Palacio FJ, Ortiz-Gomez JR, Fornet I, Lopez MA, Morillas P. [Remi- ants: Comparison of Remifentanil and Alfentanil. Anesth Pain.
fentanil bolus for cesarean section in high-risk patients: study of 2012;1(3):210-11.
12 cases]. Rev Esp Anestesiol Reanim. 2008;55(2):86-9. 24. Imani F, Alebouyeh MR, Taghipour-Anvari Z, Faiz SHR. Use of
15. Hinova A, Fernando R. Systemic remifentanil for labor analgesia. remifentanil and alfentanil in endotracheal intubation: a com-
Anesth Analg. 2009;109(6):1925-9. parative study. Anesth Pain. 2011;1(2):61-5.
16. Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth. 25. Imani F, Jafarian A, Hassani V, Khan ZH. Propofol-alfentanil vs
2010;54(5):400-8. propofol-remifentanil for posterior spinal fusion including
17. Bouattour L, Ben Amar H, Bouali Y, Kolsi K, Gargouri A, Khemak- wake-up test. Br J Anaesth. 2006;96(5):583-6.
Anesth Pain.2012;2(2) 93