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TARGET-CONTROLLED VS. BOLUS FENTANYL ADMINISTRATION IN CABG

Department of Anesthesia, St. Boniface General Hospital, 409 Taché Ave, Winnipeg, Manitoba, R2H 2A6

INTRODUCTION

Target-controlled infusion (TCI) of fentanyl has theoretical advantages over bolus administration in patients undergoing coronary artery bypass grafting (CABG).

METHODS

After IRB approval, 33 consenting patients undergoing elective CABG entered a randomized, double-blind trial comparing two methods of fentanyl administration. Anesthesia was induced with thiopental and fentanyl and maintained with isoflurane. Group TCI (n=17) received TCI fentanyl using the program STANPUMP. The target effect-site concentrations were 5 ng/ml prior to periaortic dissection and then 1.5 ng/ml until skin closure. Group B (n=16) received the same estimated total fentanyl dose as a single bolus. Measured variables included hemodynamics, end-tidal isoflurane concentration (ET-ISO), arterial fentanyl concentration, and recovery parameters. Student's t-test and analysis of variance with post-hoc Tukey's test were used appropriately (significance level P< 0.05).

RESULTS

Total fentanyl dose was slightly but significantly greater in Group TCI than in Group B (14.6±2.5 µg/kg vs. 13.0±0.9 µg/kg). Fentanyl concentrations were higher in Group TCI than in Group B at sternotomy (5.4±2.0 vs. 3.5±0.9 ng/ml) and periaortic dissection (4.9±1.1 vs. 3.0±.0.9), but not different at end-surgery (1.4±0.4 vs. 1.4±0.5 ng/ml). At intubation, Group B patients required less isoflurane and had lower mean arterial pressure (MAP) and heart rate (HR) compared to Group TCI. In contrast, during skin incision, sternotomy, sternal spread and periaortic dissection, isoflurane requirements and/or MAP were lower in Group TCI. Between Groups TCI and B respectively, time to extubation (8.0±3.1 vs. 6.5±3.7 h), ICU stay (23±14 vs 26±11 h), VAS pain scores and patient satisfaction did not differ.

DISCUSSION

TCI fentanyl was more effective than bolus administration during prebypass surgery, but the converse was true at intubation. These differences were minor, and neither regimen improved recovery. Given its simplicity, bolus fentanyl administration is preferable to TCI in patients undergoing CABG. Pharmacokinetic modeling suggests that a divided dose fentanyl bolus regimen (half at induction, half at incision) would be nearly ideal. A shorter-acting opioid than fentanyl is needed to exploit the potential advantages of TCI in CABG.

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