title: Fentanyl augments the blockade of the sympathetic response to incision (MAC-BAR) produced by desflurane and isoflurane: desflurane and isoflurane MAC-BAR without and with fentanyl.
abstract: BACKGROUND
  Heart rate (HR) or mean arterial blood pressure (MAP) may increase in response to incision despite the absence of a motor response. The authors hypothesized that the MAC-BAR (minimum alveolar concentration of an anesthetic that blocks adrenergic response to incision) for isoflurane would exceed that for desflurane, and that fentanyl would decrease the MAC-BAR for each anesthetic in a dose-dependent manner.
  
  
  METHODS
  Seventy-one patients were randomly allocated to one of six groups: desflurane or isoflurane without fentanyl or with 1.5 or 3 microg/kg fentanyl given intravenously 5 min before surgical incision. Anesthesia was induced with 2 mg/kg propofol given intravenously, and tracheal intubation facilitated with 0.1 mg/kg given intravenously. The first patient in each group received 1 MAC (end-tidal) of the inhaled anesthetic in 60% nitrous oxide (0.55 MAC), balance oxygen, maintained for at least 10 min before incision. The response was considered positive if the HR or MAP increased 15% or more. If the response was positive, the end-tidal concentration given to the next patient was 0.3 MAC greater; if the response was negative, the end-tidal concentration was 0.3 MAC less. The MAC-BAR level was calculated as the mean of four independent cross-over responses in each group.
  
  
  RESULTS
  Desflurane and isoflurane anesthesia with 60% nitrous oxide did not change HR (P > 0.05) and decreased MAP (P < 0.05) before incision. Plasma epinephrine and norepinephrine concentrations after anesthesia and before incision were normal in all groups. The MAC-BAR level, without fentanyl, did not differ (P > 0.05) between desflurane (1.30 +/- 0.34 MAC [mean +/- SD]) and isoflurane (1.30 +/- 0.18 MAC). Fentanyl given at 1.5 microg/kg intravenously equivalently (P > 0.05) reduced the MAC-BAR for desflurane (to 0.40 +/- 0.18 MAC; P < 0.05) and isoflurane (to 0.55 +/- 0.00 MAC; P < 0.05), but a further increase in fentanyl to 3 microg/kg caused no greater decrease in the MAC-BAR for desflurane (0.48 +/- 0.16 MAC) and isoflurane (0.40 +/- 0.30 MAC).
  
  
  CONCLUSIONS
  Clinically attainable doses of desflurane and isoflurane, in 60% nitrous oxide (0.55 MAC), block the cardiovascular response to surgical incision at 1.3 MAC. Fentanyl given at 1.5 microg/kg decreases the MAC-BAR for each agent with no further decrease produced by 3 microg/kg fentanyl.
authors.affiliation: Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, USA.
authors.forename: M
authors.initials: M
authors.lastname: Daniel
authors.forename: R B
authors.initials: RB
authors.lastname: Weiskopf
authors.forename: M
authors.initials: M
authors.lastname: Noorani
authors.forename: E I
authors.initials: EI
authors.lastname: Eger
mesh_terms: D000293:Adolescent; D000328:Adult; D000701:Analgesics, Opioid / Q000494:pharmacology*; D018685:Anesthetics, Inhalation / Q000494:pharmacology*; D000077335:Desflurane; D004357:Drug Synergism; D005283:Fentanyl / Q000494:pharmacology*; D006801:Humans; D007530:Isoflurane / Q000031:analogs & derivatives* / Q000493:pharmacokinetics / Q000494:pharmacology*; D008875:Middle Aged; D013564:Sympathetic Nervous System / Q000187:drug effects*
chemical_list: D000701:Analgesics, Opioid; D018685:Anesthetics, Inhalation; D000077335:Desflurane; D007530:Isoflurane; D005283:Fentanyl