Use of remifentanil in a patient with chronic hepatic failure

Abstract

SummaryWe describe a 73-yr-old woman anaesthetized for a laminectomy. She suffered from hepatic failure with mild encephalopathy complicated by several exacerbations associated with sedative and opioid therapy. The challenge for anaesthesia management was to provide adequate analgesia and avoid causing hepatic encephalopathy during and after the surgery. We used remifentanil to provide intraoperative and postoperative analgesia, because it has a short duration of action and does not require hepatic metabolism. We closely monitored the respiratory and the neurological status throughout the administration and conclude that remifentanil can provide perioperative analgesia in patients at risk Remifentanil is licensed in Switzerland for use as an analgesic in the immediate postoperative period, with the supervision of staff trained in the recognition and treatment of the respiratory effects of powerful opioids. Case reportA 73-yr-old woman suffered from a painful arachnoid cyst at the thoracic level, with a Brown-Séquard syndrome. She was being treated with tramadol (Tramal, Grünenthal), morphine (MST Continus, Mundipharma) and ibuprofen (Brufen, Knoll Pharmaceuticals). She had a 10-yr history of hepatitis C complicated by cirrhosis with frequent minor episodes of memory loss, mild confusion and irritability. She had experienced three episodes of severe hepatic encephalopathy in the preceding eight months, associated with administration of sedative or opioid drugs. The first one was precipitated by a minor gastric ulcer haemorrhage and diazepam (Valium, Roche) medication. The two other episodes occurred without gastrointestinal haemorrhage, but in association with morphine or tramadol administration. Each episode resolved satisfactorily with lactulose, a low protein diet and removal of the likely precipitating drugs. The clinical features of these episodes and EEG findings were characteristic of hepatic encephalopathy rather than simple opioid intoxication.In order to alleviate her continuous pain, and reduce the drug treatment, surgical resection of the cyst was planned. The patient did not receive premedication. Anaesthesia was induced with propofol 2 mg kg 91 (Disoprivan, Zeneca), remifentanil 1 g kg 91 (Ultiva, Glaxo Welcome) and intubation was facilitated by atracurium 0.5 mg kg 91 (Tracrium, Glaxo Welcome). Anaesthesia was maintained with 50% nitrous oxide/oxygen, isoflurane 0.5-0.8 MAC (Forene, Abbott) and remifentanil infusion at a rate of 0.25 to 0.5 g kg 91 min 91 . The monitoring included ECG, arterial pressure by the radial artery catheter, pulse oximetry, rectal temperature, and anaesthetic gas and carbon dioxide analysis. One hour before operation the patient received platelet concentrates and fresh frozen plasma to correct the blood coagulation defect. Intraoperatively 2 litres of crystalloid (glucose 5%-NaCl 0.45 %) were administered. After induction of anaesthesia, a decrease in arterial pressure to 85/40 mm Hg necessitated administration of i.v. ephedrine 10 mg to restore the arterial pressure to th...

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“…[98][99][100] Similarly, short-acting opioids such as remifentanil are metabolized by plasma esterase bypassing hepatic metabolism altogether, allowing for safe use in patients with advanced liver disease. 101 If endotracheal intubation is required, special precautions including rapid sequence intubation should be taken to prevent aspiration, especially in patients with refractory ascites. It is particularly important in patients with PH to avoid hypercarbia, which can cause excessive sympathetic stimulation and splanchnic vasoconstriction.…”

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