Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl.
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 microg 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-alpha 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.
Winterhalter
M
M
Hannover Medical School, Department of Anaesthesiology, Hannover, Germany. Winterhalter.Michael@mh-hannover.de
Brandl
K
K
Rahe-Meyer
N
N
Osthaus
A
A
Hecker
H
H
Hagl
C
C
Adams
H A
HA
Piepenbrock
S
S
D000324:Adrenocorticotropic Hormone / Q000187:drug effects / Q000378:metabolism; D000368:Aged; D018685:Anesthetics, Inhalation / Q000627:therapeutic use; D018686:Anesthetics, Intravenous / Q000008:administration & dosage / Q000494:pharmacology*; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage / Q000494:pharmacology*; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism; D007249:Inflammation / Q000209:etiology; D007262:Infusions, Intravenous; D007275:Injections, Intravenous; D007378:Interleukins / Q000378:metabolism; D008297:Male; D008738:Methyl Ethers / Q000627:therapeutic use; D008875:Middle Aged; D010880:Piperidines / Q000008:administration & dosage / Q000494:pharmacology*; D000077208:Remifentanil; D000077149:Sevoflurane; D013312:Stress, Physiological / Q000378:metabolism*; D013997:Time Factors; D014667:Vasopressins / Q000187:drug effects / Q000378:metabolism
D018685:Anesthetics, Inhalation; D018686:Anesthetics, Intravenous; D007378:Interleukins; D008738:Methyl Ethers; D010880:Piperidines; D014667:Vasopressins; D000077149:Sevoflurane; D000324:Adrenocorticotropic Hormone; D000077208:Remifentanil; D005283:Fentanyl; D006854:Hydrocortisone