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Remifentanil and controlled hypotension; comparison with nitroprusside or esmolol during tympanoplasty

Christian-S. Degoute, MD PhD^*, Marie-J. Ray, MD^*, Monique Manchon, PHARMD, Christian Dubreuil, MD and Vincent Banssillon, MD^*

^* From the Departments of Anesthesiology,
Service of Biochemistry,
Department of ENT Surgery, Centre Hospitalo-Universitaire Lyon-Sud, France.

Address correspondence to: Dr. Christian-S. Degoute, Service d'Anesthésie-réanimation, Centre Hospitalo-Universitaire Lyon-Sud, 69495-Pierre-Bénite-Cedex, France. Phone: 33-4-7886-1953; Fax: 33-4-7886-3336; E-mail: degoute{at}cismsun.univ-lyon1.fr

Purpose: To determine whether remifentanil, combined with propofol, could induce controlled hypotension, reduce middle ear blood flow (MEBF) measured by laser-Doppler flowmetry, provide a "dry" operative field, and could be compared with nitroprusside or esmolol combined with alfentanil and propofol.

Methods: Thirty patients undergoing tympanoplasty and anesthetized with 2.5 mg•kg^–1 propofol iv followed by a constant infusion of 120 µg•kg^–1•min^–1, were randomly assigned in three groups to receive either 1 µg•kg^–1 remifentanil iv followed by a continuous infusion of 0.25 to 0.50 µg•kg^–1•min^–1, or nitroprusside iv, or esmolol iv combined for the latter two groups with alfentanil iv.

Results: Controlled hypotension was achieved at the target pressure of 80 mmHg within 107 ± 16, 69 ± 4.4, 53.3 ± 4.4 sec for remifentanil, nitroprusside and esmolol respectively. MEBF decreased by 24 ± 0.3, 22 ± 3.3, 37 ± 3% and preceded the decrease in SABP, within 30 ± 6.1, 11.2 ± 3.1, 15 ± 2.8 sec for remifentanil, nitroprusside and esmolol respectively. Remifentanil, and nitroprusside decreased MEBF autoregulation less than esmolol (0.36 ± 0.1, 0.19 ± 0.2, -0.5 ± 0.2). Controlled hypotension was sustained in all three groups throughout surgery, and the surgical field rating decreased in a range of 80% in all three groups. Nitroprusside decreased pH and increased PaCO₂ . There were no postoperative complications in any of the groups.

Conclusions: Remifentanil combined with propofol enabled controlled hypotension, reduced middle ear blood flow and provided good surgical conditions for tympanoplasty with no need for additional use of a potent hypotensive agent.

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