title: Intrathecal versus IV fentanyl in pediatric cardiac anesthesia.
abstract: Systemic large-dose opioids are widely used in pediatric cardiac anesthesia, but there are no randomized, prospective studies regarding the use of intrathecal (IT) opioids for these procedures. In this randomized, prospective study, we compared cardiovascular and neurohumoral responses during IT or IV fentanyl anesthesia for pediatric cardiac surgery. Thirty children aged 6 mo to 6 yr were anesthetized with an IV fentanyl bolus of 10 micro g/kg. This was followed by a fentanyl infusion of 10 micro g. kg(-1). h(-1) (Group IV; n = 10), 2 micro g/kg of IT fentanyl (Group IT; n = 10), or combined IV and IT protocols (Group IV + IT; n = 10). Heart rate, mean arterial blood pressure, additional fentanyl doses, time to first analgesic requirement, COMFORT and Children's Hospital of Eastern Ontario Pain Scale scores, and extubation time were recorded. Blood cortisol, insulin, glucose, and lactate levels were measured presurgery, poststernotomy, during the rewarming phase of cardiopulmonary bypass (CPB), and 6 and 24 h after surgery. The patients' urinary cortisol excretion rates were also measured during the first postoperative day. The findings in all three groups were statistically similar, except for higher blood glucose levels during CPB in Group IT compared with Group IV (P < 0.004). Group IV + IT was the only group in which the increases in heart rate and mean arterial blood pressure from presurgery to poststernotomy were not significant. The 24-h urinary cortisol excretion rates ( micro g. kg(-1). d(-1)) were 61.51 +/- 39, 92.54 +/- 67.55, and 40.15 +/- 29.69 for Groups IV, IT, and IV + IT, respectively (P > 0.05). A single IT injection of fentanyl 2 micro g/kg offers no advantage over systemic fentanyl (10 micro g/kg bolus and 10 micro g. kg(-1). h(-1)) with regard to hemodynamic stability or suppression of stress response. The combination of these two regimens may provide better hemodynamic stability during the pre-CPB period and may be associated with a decreased 24-h urinary cortisol excretion rate.
  
  
  CONCLUSIONS
  In this prospective, randomized study, we investigated the adequacy of a single intrathecal injection of fentanyl for intraoperative analgesia, compared the effects of IT and IV fentanyl on stress response, and assessed for an additive effect of IT and IV fentanyl administration in pediatric cardiac anesthesia. The results with these three different anesthetic regimens were similar regarding anesthesia depth and level of stress response. However, the combination of IT and IV routes may provide better hemodynamic stability and a less pronounced stress response, as reflected by 24-h urinary cortisol excretion.
authors.affiliation: Department of Anesthesiology, Başkent University Faculty of Medicine, No. 45 Bahçelievler, 06490 Ankara, Turkey. arashpirat@hotmail.com
authors.forename: Arash
authors.initials: A
authors.lastname: Pirat
authors.forename: Elif
authors.initials: E
authors.lastname: Akpek
authors.forename: Gülnaz
authors.initials: G
authors.lastname: Arslan
mesh_terms: D018686:Anesthetics, Intravenous / Q000008:administration & dosage; D001784:Blood Gas Analysis; D001786:Blood Glucose / Q000378:metabolism; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D002648:Child; D002675:Child, Preschool; D004311:Double-Blind Method; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007223:Infant; D007278:Injections, Spinal; D007328:Insulin / Q000097:blood; D019344:Lactic Acid / Q000097:blood; D008297:Male; D010149:Postoperative Pain / Q000188:drug therapy; D011446:Prospective Studies; D013312:Stress, Physiological / Q000503:physiopathology
chemical_list: D018686:Anesthetics, Intravenous; D001786:Blood Glucose; D007328:Insulin; D019344:Lactic Acid; D005283:Fentanyl; D006854:Hydrocortisone