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Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl

Published online by Cambridge University Press:  01 April 2008

M. Winterhalter ,
K. Brandl ,
N. Rahe-Meyer ,
A. Osthaus ,
H. Hecker ,
C. Hagl ,
H. A. Adams  and
S. Piepenbrock
M. Winterhalter*
Affiliation:
Hannover Medical School, Department of Anaesthesiology, Hannover, Germany
K. Brandl
Affiliation:
Hannover Medical School, Department of Anaesthesiology, Hannover, Germany
N. Rahe-Meyer
Affiliation:
Hannover Medical School, Department of Anaesthesiology, Hannover, Germany
A. Osthaus
Affiliation:
Hannover Medical School, Department of Anaesthesiology, Hannover, Germany
H. Hecker
Affiliation:
Hannover Medical School, Department of Biometry, Hannover, Germany
C. Hagl
Affiliation:
Hannover Medical School, Division of Thoracic and Cardiovascular Surgery, Hannover, Germany
H. A. Adams
Affiliation:
Hannover Medical School, Department of Anaesthesiology, Hannover, Germany
S. Piepenbrock
Affiliation:
Hannover Medical School, Department of Anaesthesiology, Hannover, Germany
*
Correspondence to: Michael Winterhalter, Department of Anaesthesiology, Hannover Medical School, Carl-NeubergStraße 1, 30625 Hannover, Germany. E-mail: [email protected]; Tel: +49-511-532-3139; Fax: +49-511-532-3642
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Summary

Background and objective

Our aim was to compare a continuous infusion of remifentanil with intermittent boluses of fentanyl as regards the perioperative hormonal stress response and inflammatory activation in coronary artery bypass graft patients under sevoflurane-based anaesthesia.

Methods

In all, 42 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass were prospectively randomized to a fentanyl group (n = 21, total fentanyl dose 2.6 ± 0.3 mg), or a remifentanil group (n = 21, infusion rate 0.25 μg kg−1 min−1). Haemodynamics, plasma levels of epinephrine, norepinephrine, antidiuretic hormone, adrenocorticotropic hormone, cortisol, complement activation (C3a, C5b-9), interleukin (IL)-6, IL-8 and tumour necrosis factor-α were measured at T1: baseline, T2: intubation, T3: sternotomy, T4: 30 min on cardiopulmonary bypass, T5: end of surgery and T6: 8 h postoperatively. Troponin T and creatine kinase-MB were measured postoperatively.

Results

Patients in the remifentanil group were extubated significantly earlier than fentanyl patients (240 ± 182 min vs. 418 ± 212 min, P = 0.006). Stress hormones 30 min after start of cardiopulmonary bypass showed higher values in the fentanyl group compared to the remifentanil group (antidiuretic hormone (ADH): 39.94 ± 30.98 vs. 11.7 ± 22.8 pg mL−1, P = 0.002; adrenocorticotropic hormone: 111.5 ± 116.8 vs. 21.81 ± 24.71 pg mL−1, P = 0.01; cortisol 185 ± 86 vs. 131 ± 82 ng mL−1, P = 0.04). The interleukins were significantly higher at some perioperative time points in the fentanyl group compared to the remifentanil group (tumour necrosis factor: T5: 3.57 vs. 2.37; IL-6: T5: 4.62 vs. 3.73; and IL-8: T5: 4.43 vs. 2.65 and T6: 2.61 vs. 1.13). However, cardiopulmonary bypass times and aortic cross-clamp times were longer in the fentanyl group, which may to some extent account for the differences.

Conclusions

The perioperative endocrine stress response was attenuated in patients supplemented with continuous remifentanil infusion as compared to intermittent fentanyl.

Keywords

CARDIAC SURGERYCARDIOPULMONARY BYPASSANALGESICS OPIOID, fentanyl, remifentanilMONITORING PHYSIOLOGICENDOCRINE SYSTEM, stress response
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 25 , Issue 4 , April 2008 , pp. 326 - 335
Copyright
Copyright © European Society of Anaesthesiology 2007

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