Attenuation of cardiovascular stress response to endotracheal intubation by the use of remifentanil in patients undergoing Cesarean delivery

Abstract

The induction-delivery time during Cesarean section is traditionally conducted under light anesthesia because of the possibility of anesthesia-induced neonatal respiratory depression. The serious consequences of such an approach could be the increased risk of maternal intraoperative awareness and exaggerated neuroendocrine and cardiovascular stress response to laryngoscopy, endotracheal intubation, and surgical stimuli. Here, we briefly discuss the various pharmacological options for attenuation of stress response to endotracheal intubation during Cesarean delivery and then focus on remifentanil, its pharmacokinetic properties, and its use in anesthesia, both in clinical studies and case reports. Remifentanil intravenous bolus doses of 0.5-1 μg/kg before the induction to anesthesia provide the best compromise between attenuating maternal stress response and minimizing the possibility of neonatal respiratory depression. Although neonatal respiratory depression, if present, usually resolves in a few minutes without the need for prolonged resuscitation measures, health care workers skilled at neonatal resuscitation should be present in the operating room whenever remifentanil is used.

The effect of remifentanil used during caesarean section on maternal hemodynamics and neonatal outcome - comparison of two dosing regimens

“…The paper is part of Marija Kutlešić's doctoral thesis and presents some of the results that will be processed and published in the thesis. Ефекат примене ремифентанила током царског реза на хемодинамику породиље и неонатални исход -поређење два режима дозирања Марија С. Кутлешић 1,2 , Светлана Павловић 1,3 , Ранко М. Кутлешић 2,3…”

“…When performing general anesthesia for caesarean delivery, anesthetists can experience conflicting situation called "the dilemma of obstetrics anesthesia. " It is important to ensure an appropriate maternal level of anesthesia, while avoiding neonatal respiratory depression caused by the medications that parturient receives [1,2]. Resolving the problem of neonatal well-being by reducing as much as possible doses of anesthetics given to the mother and omission of opioids during induction to delivery period (I-D), result in light anesthesia with increased risk of intraoperative awareness and exaggerated neuroendocrine stress response to surgical stress, possibly leading to severe cardio-and cerebrovascular complications [1][2][3][4][5].…”

“…It is important to ensure an appropriate maternal level of anesthesia, while avoiding neonatal respiratory depression caused by the medications that parturient receives [1,2]. Resolving the problem of neonatal well-being by reducing as much as possible doses of anesthetics given to the mother and omission of opioids during induction to delivery period (I-D), result in light anesthesia with increased risk of intraoperative awareness and exaggerated neuroendocrine stress response to surgical stress, possibly leading to severe cardio-and cerebrovascular complications [1][2][3][4][5]. Remifentanil, ultra-short acting synthetic opioid, could be the appropriate drug to use for the attenuation of maternal stress response during the I-D interval, where a brief but intense analgesia without prolonged effect is desirable [2,4,[6][7][8][9].…”

“…Remifentanil has rapid onset of action (1-1.5 min. ), rapid redistribution and metabolism dependent on nonspecific tissue and plasma esterases; its context sensitive half time is three min; it crosses the placenta, but appears to be rapidly metabolized and redistributed in the fetus, leaving the small possibility of neonatal adverse effects [2,4,7,9,10].…”

“…In studies reporting the use of remifentanil during the I-D period dosing regimens were different; hemodynamic stability was often achieved at the expense of neonatal respiratory depression [2,4,[6][7][8][9][11][12][13][14][15][16]. In the present study, we investigated the effects of two remifentanil dosing regimens, used during the I-D period, on maternal hemodynamics and neonatal outcome in attempt to find the best compromise between the attenuation of maternal stress response and avoidance of neonatal adverse effects.…”