The effects of remifentanil and alfentanil-based total intravenous anesthesia (TIVA) on the endocrine response to abdominal hysterectomy

doi:10.1016/j.jclinane.2003.10.002

Journal of Clinical Anesthesia

Volume 16, Issue 5, August 2004, Pages 358-363

https://doi.org/10.1016/j.jclinane.2003.10.002 Get rights and content

Abstract

Study objective

To compare the effects of remifentanil with alfentanil as a part of total intravenous anesthesia (TIVA) on plasma concentrations of cortisol, insulin, and glucose, and hemodynamic responses in patients undergoing abdominal hysterectomy.

Design

Randomized, double-blind study.

Setting

University hospital.

Patients

24 ASA physical status I female patients scheduled for abdominal hysterectomy.

Interventions

Premedicated patients were randomly allocated to receive either remifentanil-propofol (Group R) or alfentanil-propofol (Group A). The loading dose of the study drug was administered over 60 seconds (remifentanil l μg kg^−l or alfentanil 10 μg kg^−l) followed by a continuous infusion (remifentanil 0.2 μg kg^−l min^−l or alfentanil 0.5 μg kg^−l min^−l). In both groups, propofol was administered until loss of consciousness and maintained with a propofol infusion rate of 100 μg kg^−l min^−l. After induction of anesthesia, all patients were manually ventilated by mask with O₂-air mixture for 20 minutes. Then rocuronium 0.6 mg kg^−l was given for tracheal intubation.

Measurements

Mean arterial pressure (MAP) and heart rate (HR) were recorded. Plasma concentrations of cortisol, insulin, and glucose were measured during anesthesia and in the recovery room.

Main results

In Group R, MAP and HR were lower after tracheal intubation and skin incision than in Group A (p < 0.05). Plasma cortisol concentrations decreased from baseline values at 20 minutes after induction, after tracheal intubation, and skin incision in Group R (p < 0.001). Plasma concentrations of cortisol and glucose increased from baseline values at 30 minutes after skin incision and continued to increase in both groups (p = 0.001). Plasma concentrations of cortisol, insulin, and glucose did not differ between groups at all sampling times.

Conclusion

Remifentanil provided better hemodynamic stability than alfentanil during anesthesia and surgery. However, both remifentanil and alfentanil had similar effects on the stress endocrine response to abdominal hysterectomy.

Introduction

Remifentanil is a highly potent μ-opioid receptor agonist, belonging to the class of 4-anilopiperidine derivates. The onset of action of remifentanil is similar to that of alfentanil. However, unlike other opioids, it has a rapid offset of action due to its metabolism by nonspecific blood and tissue esterases.1, 2, 3

Total intravenous anesthesia (TIVA) regimen with remifentanil and propofol is a useful anesthetic technique, effectively controlling responses to tracheal intubation and intense surgical stimulation while allowing for rapid emergence from anesthesia.4 In addition, clinical studies have shown that remifentanil provides better intraoperative hemodynamic stability than does alfentanil.1, 5, 6

Surgery evokes an endocrine response that is characterized by the enhanced secretion of catabolic hormones, such as cortisol and catecholamines, and a decrease in anabolic hormones, such as insulin and testosterone.7, 8 To date, there have been no studies in the literature that have compared the effects of remifentanil and alfentanil anesthesia on the endocrine response to surgery.

The aims of this study were to compare the effects of propofol-remifentanil and propofol-alfentanil anesthesia on plasma concentrations of cortisol, insulin, and glucose, and hemodynamic changes.

Section snippets

Materials and methods

After Ethics Committee Approval by the Medical Faculty of Harran University, and patients' written, informed consent, 24 female, ASA physical status I patients, scheduled to undergo elective abdominal hysterectomy, were studied. None of the patients had cardiovascular, renal, hepatic, or hormonal disorders, or was receiving any medication. On the day of surgery, patients were allocated, via a table of random numbers, to receive either remifentanil-propofol anesthesia (Group R, n = 12) or

Results

Demographic characteristics, as well as the duration of anesthesia and surgery, were similar between groups (Table 1 ).

An increase in MAP was primarily a hemodynamic response to stimuli. The number of patients with response to intubation, skin incision, and surgical stimuli were higher in Group A than Group R, although these differences did not reach statistical significance (Table 2). Hypotension (requiring decreases in opioid infusion rates) occurred in three patients in Group R and one

Discussion

In our study, the occurrence of hypertension and tachycardia in response to intubation, skin incision, and surgical stimuli was controlled effectively by both anesthetic regimens. Because of the pharmacokinetic differences between the two opioids, it was not possible to administer alfentanil infusions at an equipotent dose to remifentanil because of the risk of delayed recovery and prolonged respiratory depression at higher infusion doses of alfentanil.¹ Therefore, the infusion rate of study

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This study tested the hypothesis that remifentanil infusion decreases both hyperglycaemia and insulin requirement during cardiac surgery, based on the assumption that the hormonal stress response, as opposed to decreased insulin secretion, is the major driver of hyperglycaemia during cardiac surgery.2,7 Remifentanil was chosen as it has been shown to suppress the stress response during various surgical procedures.8–13 Fewer patients in the remifentanil group had hyperglycaemic episodes during surgery, despite receiving less insulin.
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The trial included 106 subjects in the final intention-to-treat analysis. There were fewer patients with ≥2 intraoperative blood glucose values >10 mM (180 mg dl⁻¹) in the remifentanil group (17 [31.5%]) compared with the fentanyl group (33 [63.5%]) (relative risk: 0.50; 95% confidence interval [CI]: 0.32–0.77; P=0.001). The administered intraoperative insulin was a median of 8.1 units (range: 0–46.7) in the fentanyl group and 2.9 units (range: 0–35.1) in the remifentanil group (median difference=5 units; 95% CI: 1–7; P=0.004). Cortisol and adrenocorticotropic hormone were increased less in the remifentanil group (P<0.001), but there was no relative decrease in this group in select inflammatory cytokines. Postoperative measures of glycaemic control and adverse clinical outcomes were not significantly different between groups.
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^*: Assistant Professor of Anesthesiology

^†: Assistant Professor of Biochemistry

^‡: Research Anesthesiologist

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Original contributionThe effects of remifentanil and alfentanil-based total intravenous anesthesia (TIVA) on the endocrine response to abdominal hysterectomy

Abstract

Study objective

Design

Setting

Patients

Interventions

Measurements

Main results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

J Clin Anesth

Br J Anaesth

Br J Anaesth

Br J Anaesth

Remifentanil compared with alfentanil for ambulatory surgery using total intravenous anesthesia. The Remifentanil/Alfentanil Outpatient TIVA Group

Anesth Analg

Remifentanil

Drugs

A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient surgery

Anesth Analg

A comparison of remifentanil and alfentanil in patients undergoing major abdominal surgery

Anaesthesia

Original contribution
The effects of remifentanil and alfentanil-based total intravenous anesthesia (TIVA) on the endocrine response to abdominal hysterectomy