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* From the Departments of Anesthesiology, Mayo Clinic, Rochester, Minnesota,
and The Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Address correspondence to: Dr. John A. Dilger, Department of Anesthesiology, Mayo Clinic, 200 First Street, S.W., Rochester, Minnesota 55905, USA. Phone: 507-284-9700; Fax: 507-284-0120; E-mail: dilger.john{at}mayo.edu
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Abstract |
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Methods: Sixty patients received sedation with propofol (50 µg•kg-1•min-1). After receiving a loading dose of opioid (either remifentanil 0.5 µg•kg-1, or alfentanil 2.5 µg•kg-1), an infusion was initiated (remifentanil 0.05 µg•kg-1•min-1 or alfentanil 0.25 µg•kg-1•min-1), and this was supplemented with local anesthetic infiltration. The pain was evaluated with a ten-point visual analogue scale (VAS) during local anesthetic infiltration and deep tissue dissection. Inadequate analgesia, defined as VAS scores 
5, was treated first with boluses of opioid (remifentanil group 10 µg or alfentanil group 50 µg) and if inadequate after two treatments with additional local anesthetic. Postoperative times were recorded including the times until discharge criteria were achieved and patient’s actual discharge.
Results: The pain scores were similar between the two groups during the initial injections of local anesthetic in the breast, however, patients in the remifentanil group had lower mean pain scores during deep tissue dissection (2.3 vs 4.3, P < 0.01). Patients in the remifentanil group required fewer rescue doses of opioid (1.9 vs 3.6, P < 0.03) and local anesthetic (5 vs 15, P < 0.006). The two study groups had comparable speed of recovery.
Conclusion: Remifentanil was a better opioid choice than alfentanil for breast biopsy under MAC at the doses studied, but it did not increase the rapidity in which patients recovered postoperatively.
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Introduction |
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The purpose of this study was to test the hypothesis that remifentanil may be an advantageous opioid over alfentanil for breast biopsy surgery. We hypothesized that pain scores would be lower, that patients would be discharged faster from the hospital as a result of the drug’s rapid metabolism, and that patient satisfaction would be superior.
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Methods |
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). We excluded the following patients/conditions: hypersensitivity or intolerance to opioids, chronic use of opioids for pain, alcohol or drug abuse, and those who were morbidly obese [body mass index (BMI) > 35]. The opioid solutions were prepared by an anesthesia provider not involved in the study who provided both bolus and maintenance syringes for the two groups. The anesthesiologist was blinded to the opioid used during the surgery. The maintenance concentrations were adjusted to 10 µg•mL-1 for remifentanil and 50 µg•mL-1 for the alfentanil, so the infusion rates in both groups, in millilitres per hour, were the same.
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During surgery heart rate, blood pressure, oxyhemoglobin saturation (SpO2), and respiratory rate were recorded at baseline and throughout the procedure. Study personnel (anesthesiologist in charge or anesthesia research personnel) evaluated the level of pain with a ten-point visual analogue scale (VAS) during local anesthetic infiltration and during the deep dissection of the breast tissue. The patients were asked to rate their pain scores verbally. In addition, at the same time the level of sedation was assessed by using the Observer’s Assessment of Alertness/Sedation (OAA/S) scale, with 5 = awake/alert to 1 = asleep/unarousable. Providing OAA/S was rated as 1, and the patient did not show physical evidence of pain (grimacing, moving, etc.), the VAS was counted as 0 (no pain). Inadequate analgesia, defined as VAS scores 5, was treated first with boluses of opioid solution (remifentanil 10 µg or alfentanil 50 µg) and, if inadequate after two treatments, with the additional infiltration of the surgical field with local anesthetic. The number of opioid boluses and volumes and numbers of local anesthetic boluses were recorded for analysis. Patients were monitored for signs of excessive sedation. The opioid infusion was scheduled to be discontinued if the respiratory rate was less than 8 breaths•min-1 or if despite supplemental oxygen, the pulse oximetry values were below 90%. If respiration was unaffected, the propofol and study infusions were continued unchanged until skin closure. The last skin stitch was counted as the end of surgery to calculate the length of the procedure.
Patients were transferred to the step down recovery (phase II) unit after surgery. We recorded the time until discharge criteria were achieved, and the time when the patient was actually discharged. Qualifications for discharge from phase II were defined as a postanesthesia discharge score 9 (two points each for vital signs, pain, activity, bleeding, and oral intake and voiding). We also recorded time until unassisted ambulation was achieved and the level of pain. Nausea and vomiting were scored on a four-point scale (0 = none, 1 = mild, 2 = modest, and 3 = severe). Patients were contacted by telephone the day after surgery and asked about their satisfaction with the pain control during the operation (1 = extremely satisfied, 7 = extremely dissatisfied). They were also asked if they would choose to have the same anesthetic for another procedure.
Statistical analyses were performed using the two-tailed Student t test, Fisher exact test, and Wilcoxon rank sum test (nausea and satisfaction scores) when appropriate, and P values < 0.05 were considered statistically significant. The values are presented as mean ± standard deviation.
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Results |
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). Neither group had significant hypotension, bradycardia, or respiratory depression requiring alteration of opioid infusion.
There were no differences between the remifentanil and alfentanil groups in OAA/S scores during either local anesthetic infiltration or deep tissue dissection (Table II). Similar volumes of local anesthetic were used to infiltrate the breast tissue prior to incision in both groups. While the VAS pain scores were not different during the initial local anesthetic injection, during deep tissue dissection patients in the remifentanil group had lower mean pain scores (2.3 vs 4.3, respectively, P < 0.01). Furthermore, remifentanil patients received fewer rescue doses of opioids than patients in the alfentanil group (1.9 vs 3.6, P < 0.03). Significantly more patients in the alfentanil group received rescue doses of local anesthetic (5 vs 15 patients in remifentanil and alfentanil groups, respectively, P < 0.006, Table II). Furthermore, patients requiring rescue doses of local anesthetic received more local anesthetic in the alfentanil (average 10.4 mL) than in the remifentanil (average 5.5 mL) group (Table II).
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) were different; time for ambulation, achievement of discharge criteria, and actual discharge were similar in the two groups, as was the incidence of nausea or vomiting. The postoperative follow-up interview regarding patient’s satisfaction with surgery revealed similar overall satisfaction between the two groups. Most of the patients in the two groups were very satisfied with their anesthetic treatment (Table III), and only two patients were less than somewhat dissatisfied and rated their satisfaction scores 4 and 6 in the alfentanil and remifentanil groups, respectively.
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Discussion |
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It has been shown that remifentanil is eight to 20 times more potent than alfentanil.11,12 In the present study we compared remifentanil to alfentanil in a 1:5 ratio and, at this ratio, remifentanil was a better analgesic during deep dissection of the breast tissue. The analgesic properties of remifentanil have been compared to those of alfentanil in other MAC settings. During retrobulbar blockade, patients received remifentanil or alfentanil, and those who received remifentanil had less pain during the initiation of the block.13 In contrast, in our study, initiation of blockade with lidocaine resulted in similar pain scores in the two groups. This difference may be explained by the more stimulating nature of retrobulbar block compared to the simple infiltration of breast tissue. In another study remifentanil was compared to other opioids during extracorporeal shock wave lithotripsy performed under MAC.14 Patients in this study were randomized to received remifentanil, alfentanil, sufentanil or fentanyl in a bolus fashion. Boluses of remifentanil, sufentanil, and fentanyl provided effective analgesia for lithotripsy, but remifentanil provided significantly superior analgesia compared to alfentanil14 which is in agreement with our study.
Remifentanil is 40 times more potent than alfentanil with respect to affecting minute ventilation,15 but, in our spontaneously breathing patients, there were no cases of ventilatory depression that required discontinuation of the opioid infusion. Furthermore, one may expect to encounter more pain postoperatively when remifentanil is used compared to other opioids due to the quick dissipation of its analgesic action.14 This was not the case in our study presumably because we used lidocaine to infiltrate the operative field, and this provided adequate postoperative analgesia.
Recovery times and times to discharge have been evaluated with remifentanil and alfentanil in several studies. In a study by Cartwright et al.,16 ambulatory surgery patients received general anesthesia consisting of air/isoflurane and infusions of remifentanil or alfentanil which were maintained until the end of surgery. There was no detectable difference between the groups in times to eligibility for discharge, actual discharge, or the presence of nausea and vomiting.16 Similar results were obtained by Kovac et al.17 in which patients received general anesthesia (nitrous oxide/oxygen) and were randomized to receive either remifentanil or alfentanil. Regardless of the opioid received, the patients were discharged from the recovery room in similar times and with similar incidences of nausea and vomiting. These findings are in agreement with our results despite our expectations that remifentanil patients would be discharged sooner because of its rapid elimination. The remifentanil patients in our study were eligible and ultimately discharged no sooner than the alfentanil patients, and they had similar incidence of nausea and vomiting.
In conclusion, during breast biopsy the use of remifentanil for analgesia was superior to alfentanil in providing lower pain scores while requiring fewer treatments with opioids and local anesthetics. At the same time, the short activity of the remifentanil did not allow patients to recover at an accelerated rate and did not result in difference in pain scores during the recovery period.
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Footnotes |
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Funding: This work has been funded by the Departmental funds at the Cleveland Clinic Foundation.
Accepted for publication May 26, 2003. Revision accepted September 10, 2003.
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