Effect of remifentanil infusion rate on stress response in orthopedic surgery using a tourniquet application

Abstract

BackgroundCurrently, in the field of general anesthesia, balanced anesthesia in combination with analgesic, hypnotic, and muscle relaxant is commonly used. Remifentanil is the standard analgesic used in balanced anesthesia, and has contributed greatly to reduce the physical stress of the patient during surgery. We compared the stress response suppression effect of remifentanil by measuring stress hormones in 2 groups treated with different analgesic doses in orthopedic surgery using a tourniquet.MethodsTwenty patients were randomly divided into 2 groups (10 patients each) undergoing maintenance of general anesthesia with 0.25 μg/kg/min remifentanil and sevoflurane (Group A) and 1.0 μg/kg/min remifentanil and sevoflurane (Group B). Hemodynamic changes, adrenocorticotropic hormone (ACTH), cortisol, antidiuretic hormone (ADH), adrenaline (Ad), noradrenaline (NAd), dopamine (DOA), insulin, and blood glucose were measured at the initiation of general anesthesia,10 minutes after the initiation of tourniquet application, and immediately before and 10 minutes after the completion of tourniquet application.ResultsACTH, cortisol, ADH, Ad, and NAd levels in Group B were significantly lower (ACTH and cortisol: P < 0.01, ADH, Ad, and NAd: P < 0.05) than those in Group A. No significant differences were noted in DOA, insulin, or blood glucose levels between the groups.ConclusionAnesthesia management with high-dose remifentanil (1.0 μg/kg/min) suppressed intraoperative tourniquet pain-induced stress hormone release, suggesting its usefulness in stabilizing hemodynamics.Trial registrationJMA-IIA00094

Tourniquet application during anesthesia: “What we need to know?”

“…These changes persist until tourniquet deflation and poorly respond to analgesic drugs or increasing the depth of anesthesia. Many interventions have been reported to reduce cardiovascular stress:[242526272829303132] Ketamine, dexmedetomidine, magnesium sulfate, clonidine, and remifentanil infusion.…”

“…Many techniques[27] like application of EMLA cream, infiltration with local anesthetics, use of wider cuff with lower inflation pressure, addition of opioids, clonidine, epinephrine along with local anesthetics in spinal block have been tried in order to decrease the incidence or severity of this pain but none has attained complete success in pain relief. Intravenous drugs,[242527282930313247] ketamine, dexmedetomidine, magnesium sulfate, clonidine remifentanil infusions have also been studied, and the only thing that works reliably is tourniquet deflation.…”

Drug-induced HPA axis alterations during acute critical illness: a multivariable association study

“…Previous studies have shown that anaesthetic drugs, more specifically the hypnotic etomidate, can suppress adrenocortical synthesis of cortisol . However, many other drugs may have HPA suppressive properties as suggested by small interventional studies in surgical and ICU patients, by observational studies of surgical patients and by animal experiments. Based on the available evidence, we hypothesized that the pharmacological effects of drugs used during surgery or the acute phase of critical illness prior to ICU admission may explain the acute ‘ACTH‐cortisol dissociation’, as observed upon admission to the ICU.…”

Administration of low dose of glucose suppresses catabolism under general anaesthesia maintained with remifentanil

“…In most previous studies examining the effects of intraoperative glucose administration on metabolism, general anaesthesia was maintained with fentanyl without remifentanil and the type of surgery varied. Generally speaking, remifentanil is more useful for controlling intraoperative stress [13,14]. In addition, the anaesthetic drug that was used Figure 5.…”

“…In addition, the glucose levels of the subjects in these previous studies might have been relatively high because the general anaesthesia was maintained with fentanyl instead of remifentanil, which is better at preventing hyperglycaemia as it can effectively control intraoperative stress [13,14]. Furthermore, the types of surgery performed varied between the studies, with differences in the invasiveness of the procedures and, hence, in the extent of the intraoperative stress that was induced.…”