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Remifentanil with morphine transitional analgesia shortens neurological recovery compared to fentanyl for supratentorial craniotomy

[L’analgésie transitionnelle avec du rémifentanil et de la morphine, comparés au fentanyl, diminue le temps de récupération neurologique suivant une craniotomie sus-tentorielle]

Adrian W. Gelb, MB CHB^*, Frederick Salevsky, MD, Frances Chung, MBBS, Ken Ringaert, MD, Robert M.C. McTaggart-Cowan, MD^¶, Ted Wong^* and Pirjo H. Manninen

^* From the Departments of Anaesthesia, London Health Sciences Centre, London, Ontario;
Montreal Neurological Hospital, Montreal, Quebec;
The Toronto Western Hospital, University Health Network, Toronto, Ontario;
Health Sciences Centre, Winnipeg, Manitoba;
^¶ and the Foothills Hospital, Calgary, Alberta, Canada.

Address correspondence to: Dr. Adrian W. Gelb, Department of Anaesthesia, London Health Sciences Centre - University Campus, 339 Windermere Road, London, Ontario, N6A 5A5, Canada. Phone: 519-663-3022; Fax: 519-663-3161; E-mail: agelb{at}uwo.ca.

Purpose: To compare the recovery profiles, efficacy and safety of remifentanil and morphine for transitional analgesia with fentanyl in patients undergoing elective craniotomy for supratentorial mass lesions.

Methods: Ninety-one patients were enrolled in this prospective, randomized, multicentre study. Anesthesia was induced with thiopental and remifentanil (1.0 µg•kg^-1 bolus and a 1 µg•kg^-1•min^-1 infusion) or fentanyl (1 µg•kg^-1 bolus and a 1.0 µg•kg^-1•min^-1 infusion). The opioid infusion continued until the level of anesthesia was deemed appropriate for intubation. Anesthesia was maintained with N₂O/O₂, isoflurane 0.5 MAC and remifentanil 0.2 µg•kg^-1•min^-1 or fentanyl 0.04 µg•kg^-1•min^-1. At bone flap replacement, either morphine 0.08 mg•kg^-1 (remifentanil group) or saline (fentanyl group) was given.

Results: Systolic blood pressure was greater in those receiving fentanyl during induction (145.6 ±17.5 mmHg vs 128.8 ±18.3 mmHg; P = 0.006) and intubation (126.9 ±17.1 vs 110.9 ±16.5 mmHg; P < 0.001). Median time to tracheal extubation was similar but less variable in the remifentanil group (remifentanil = 8 min: range = 2–44 min; fentanyl = 8 min: range = 1–732 min). The fentanyl patients required a longer time to achieve the first normal neurological score (fentanyl = 38.0 min; remifentanil = 26.0 min; P = 0.035). Both the anesthesiologists and the recovery room nurses rated remifentanil better with respect to level of consciousness. Analgesics were required earlier in patients receiving remifentanil; median time 0.5 vs 1.08 hr, P < 0.001.

Conclusions: Remifentanil is a suitable alternative to fentanyl in supratentorial craniotomy. Time to preoperative neurological recovery is faster and morphine provides some transitional analgesia without compromising the quality of recovery.

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