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Remifentanil-propofol versus sufentanil-propofol anaesthesia for supratentorial craniotomy: a randomized trial

Gerlach, K.*; Uhlig, T.*; Hüppe, M.*; Nowak, G.; Schmitz, A.*; Saager, L.*; Grasteit, A.*; Schmucker, P.*

European Journal of Anaesthesiology: October 2003 - Volume 20 - Issue 10 - pp 813-820
Original Article

Background and objective: Remifentanil has unique pharmacokinetics that might allow faster recovery after neurosurgery. We investigated the effects of a propofol/sufentanil versus a remifentanil/propofol regimen on the primary end-point tracheal extubation time.

Methods: In the Neurosurgery Department of a University Hospital, 36 patients awaiting craniotomy for supratentorial tumour resection were randomly assigned to one of two study groups. In the sufentanil/propofol group, anaesthesia was induced with 0.5 μg kg−1 sufentanil and 1-2 mg kg−1 propofol. Propofol infusion and boluses of sufentanil were administered for maintenance. In the remifentanil/propofol group, anaesthesia was started with an infusion of remifentanil (0.2-0.35 μg kg−1 min−1) and a bolus of propofol (1.5-2 mg kg−1). Patients received a propofol infusion and a remifentanil infusion for maintenance of anaesthesia. Recovery times were taken from cessation of the propofol infusion. In addition, data about self-reported nausea and vomiting, pain and analgesic requirements were collected.

Results: Patients in the remifentanil/propofol group were extubated earlier (mean times 6.4 (±SD 4.7) versus 14.3 (±9.2) min; P = 0.003). The two groups were similar with respect to postoperative nausea and vomiting, and patient-reported pain scores. Fifty per cent of the remifentanil/propofol patients and 88% of the sufentanil/propofol patients required no analgesics within 1 h after operation (P =0.03).

Conclusions: The remifentanil/propofol regimen provided quicker recovery. The two regimens were similar in terms of postoperative nausea and vomiting and patient-reported pain scores, but patients in the remifentanil/propofol group required more analgesics within 1 h postoperatively.

Remifentanil appears promising as an anaesthetic for craniotomy for several reasons. First, it does not alter cerebral blood flow carbon dioxide reactivity and has minimal effects on intracranial pressure and cerebral blood flow itself [1-5]. Second, it controls the acute autonomic response during neurosurgical procedures providing good haemodynamic stability [4]. Third, it has unique pharmacokinetic properties. The terminal plasma half-life of remifentanil is 8-10 min and its context-sensitive time is 3-5 min [6]. The presence of an ester side-chain allows rapid metabolism by nonspecific esterases to remifentanil acid, which is approximately 4600 times less potent than remifentanil [7]. Propofol also has potential advantages. The context-sensitive half-life of propofol infusions up to 8 h is less than 40 min [8]. Propofol decreases the cerebral metabolic rate, cerebral blood flow and intracranial pressure [9,10]. In certain types of surgery, propofol reduces the frequency of postoperative nausea and vomiting (PONV) [11], and it is possible that it has the same effect after intracranial surgery [12].

From and colleagues found only small differences when comparing alfentanil, fentanyl and sufentanil during anaesthesia for craniotomy with respect to haemodynamic variables and emergence from anaesthesia [13]. Many other anaesthetics have been used for intracranial surgery including volatile inhalation agents and N2O [4,12,14].

Quick recovery with 'fast-track' tracheal extubation may be beneficial after intracranial surgery. Neurosurgical patients are at risk of postoperative cerebral bleeding and procedural complications might be detected earlier in awake patients. In addition, prolonged endotracheal intubation is related to a higher incidence of postoperative pulmonary complications. In a recent study, patients sedated with propofol for 2 h after surgery had higher oxygen consumption and higher norepinephrine plasma concentrations than did patients extubated soon after surgery (fast-track group) [15].

One possible advantage of remifentanil could be the predictability of rapid offset of analgesic action allowing a rapid emergence from anaesthesia. The purpose of this randomized trial was to compare anaesthetists' individual practice with two TIVA regimens, sufentanil/propofol and remifentanil/propofol. This methodological approach follows criteria recommended recently by Coriat and Beaussier for clinical study designs [16]. The primary end-point of the study was extubation time. Secondary end-points were further aspects on recovery (e.g. eye opening), haemodynamics, PONV, analgesic requirements and patient pain score.

University Hospital Lübeck, Departments of *Anaesthesiology and Neurosurgery, Lübeck, Germany

Correspondence to: Klaus Gerlach, Klinik für Anästhesiologie, Universitätsklinikum Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany. E-mail:; Tel: +49 451 500 4057; Fax: +49 451 500 3405

Accepted for publication December 2002 EJA 1125

© 2003 European Academy of Anaesthesiology