Perioperative effects of ramifentanil vs fentanyl on cardiovascular and humoral response in elderly patients undergoing total gastrectomy
Creators: name: Lončar-Stojiljković, Dragana
name: Milos Stojiljković
Publisher: name: F1000Research
Year: 2017

description: The stress response to surgery, trauma, critical illness and burns encompasses derangements of metabolic and physiological processes that induce perturbations in the acute-phase-hormonal, inflammatory and genomic responses (1). The surgery-induced stress response is a controlled modality of traumatic injuries (2). The duration and strength of the stress response, however, varies according to the severity of injury (surgical or traumatic).<br><br>The stress response begins by activation of the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system, and continues in secretion of ACTH, cortisol, catecholamines, aldosterone, AVP, and glucagon in an effort to provide the host with energy, retain fluid and salt, and maintain cardiovascular homeostasis (3). This high stress state, however, can result in harmful outcomes to the host such as cardiovascular instability (hypertension, tachycardia), hyperglycemia, and immunosuppression (4).<br><br>Total gastrectomy is considered as one of the most severe upper abdominal operations (5). Elderly patients, over 65 years have many health problems, among them cardiovascular, respiratory, and psychological. For them it is very important to provide stabile state during the operation, which includes the decreasing of stress hormonal response, which will provide better cardiovascular and hormonal stability.<br><br>Opioids and anaesthetic drugs that are known to suppress hypothalamic and pituitary hormonal secretion. Upper abdominal operations demand higher doses of opioids (fentanyl&gt;50 µg/kg), which are connected with prolonged recovery from operation (6). Remifentanil, as ultra-short opioid, can  provide faster awakening, but as it is 10 times more potent than fentanyl, a question arises whether it provides better cardiovascular stability.<br>    <br>The aim of the study was to investigate wheather the ultra short-acting opioid remifentanil (7) provides better cardiovascular and humoral response control than fentanyl during and after total gastrectomy in elderly patients.<br><br>A total of 60 elderly patients scheduled for total gastrectomy were randomized in two equal groups to receive remifentanil (0.1 μg/kg continuous <i>iv </i>infusion) or fentanyl (1.5 µg/kg <i>iv </i>bolus), as analgesic part of general balanced anaesthesia and continued postoperatively for 24 hours. Values of cardiovascular parameters – blood pressure and heart rate and levels of cortisol, insulin and glycaemia were measured at seven points in time. There were no differences between the patients in the two groups regarding their age, weight and gender.      <br><br>During the operations cardiovascular parameters were not significantly changed, except in the phase of induction and intubation. After the induction in anesthesia, a significant fall in systolic (32%±5) and diastolic blood pressure (25±4%) was found in remifentanil group. In the same phase fentanyl induced a milder decrease in blood pressure. After intubation the systolic pressure was significantly increased in the fentanyl group (by 33%), while in the remifentanil group a smaller increase in systolic blood pressure was registered (by 16%) Levels of cortisol start to increase after the extubation, but significantly more in the remifentanil group. Its levels were significantly increased 12 h after the operation in both groups. Thereafter, they showed a tendency of decrease, but remained still above the preoperative values 24 h after the operation. Glucose level was significantly increased in the phase of tracheal extubation only in the remifentanil group. It showed a tendency of increasing in both groups until the end of operation. During the postoperative period its levels were within the normal rang in both groups.<br><br>Fentanyl assured better cardiovascular and humoral stability than remifentanil in elderly gastrectomised patients. Control of  cardiovascular parameters and suppression of cortisol secretions are the best humoral indicators of the mitigation of the humoral response to trauma.<br><br>There is interdependence between changes of the cardiovascular parameters induced by sympathoarenal activity and levels of the glycaemia during gastrectomy in elderly patients.<br><br> <br>REFERENCES:	Finnerty CC, Mabvuure NT, Ali A. The Surgically Induced Stress Response: <i>JPEN J Parenter Enteral Nutr</i> 2013 Sep;37:21S–29S.	Desborough JP. The stress response to surgery.<i>Br J Anaesth </i>2000; 85: 109–17	Kurosawa S, Kato M. 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