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


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Abstract

SummaryBackground 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.

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