|Year : 2009 | Volume
| Issue : 4 | Page : 455-462
Sufentanil Vs Fentanyl for Fast-Track Cardiac Anaesthesia
CM Deshpande1, SN Mohite1, Prashant Kamdi2
1 Professor, Department of Anaesthesiology, T N Medical College, Mumbai, India
2 P.G Student, Department of Anaesthesiology, B Y LNair Hospital, Mumbai, India
|Date of Web Publication||3-Mar-2010|
C M Deshpande
2124, HajiAli Govt. Colony, K.KhadyeMarg, Mumbai-400 034
Source of Support: None, Conflict of Interest: None
A perioperative anaesthetic management that aims to facilitate tracheal extubation of patients within 1-6 hrs after cardiac surgery is called "fast-track'. Main advantage of 'fast-track" method is better usage of medical resources and lowering hospital costs without increasing morbidity and mortality of the patients. Standard fast-track protocols contain short acting anaesthetic agents, smaller incisions and decreased pump times without hypothermia. In this study we compared two short acting opioid drugs, fentanyl versus Sufentanil when used as a part of the balanced anaesthesia technique for fast track in cardiac surgery patients& evaluated the time taken for extubation, haemodynamic stability, analgesia requirements& incidence of awareness. The results from the study show thatboth agents provide good haemodynamic stability and postoperative analgesia. Although Sufentanil provides earlier extubation, both agents reduce the ICU stay equally. In conclusion both agents can be used effectively for fasttrack cardiac anaesthesia.
Keywords: Fast Track Cardiac Anaesthesia (FTCA), Sufentanil, Fentanyl
|How to cite this article:|
Deshpande C M, Mohite S N, Kamdi P. Sufentanil Vs Fentanyl for Fast-Track Cardiac Anaesthesia. Indian J Anaesth 2009;53:455-62
| Introduction|| |
Opioids have been an integral part ofcardiac anaesthesiadue to their cardiostable properties. Prolonged mechanical ventilation as aconsequence of high dose opioid anaesthesia was an essential part of postopemtive care in cardiac surgery during its developing years.
A perioperative anaesthetic managementthat aims to facilitate tracheal extubation of patients within 1-6 hrs after cardiac surgery is called `fast-track' , (FTCA). Main advantage of "fast-track" method is better usage of medicalresources and lowering hospital costs without increasingmorbidity and mortality of the patients. Safety and effectiveness of fast track versus slow-track cardiac anaesthesia is proved by many studies. ,, An effective fasttrack cardiac anaesthesia program requires appropriate selection of suitable patients, a low dose opioid anesthetic technique, early tracheal extubation, a short stay in the ICU, and coordinatedperioperative care. , In this study we compared the time to extubation, haemodynamic stability and postoperative analgesia whentwo short acting opioid drugs, fentanylor Sufentanil were used as a part of the anaesthesia technique for fast trackin cardiac surgery patients. We also compared incidence of awareness associated with FTCA.
| Methods|| |
After obtaining approval from hospital academic and ethics committee and written, informed valid consent, 100 patients between the age of 15-50 years, undergoingelective open-heart surgery for valvular and simple congenitalheart disease were enrolled in this randomized, prospective, double blinded study. The study excluded patients with left ventricularejection fraction (LVEF) <20%, severe pulmonary hypertension (PH), severe COPD, renal insufficiency, severe liver disease, history of seizure or stroke, history of allergy to propofol, patients in whom cardiopulmonary bypass (CPB) time >2 hrs and pregnant patients.
All patients underwent thorough preoperative evaluation and investigations. All the cardiac medications of the patient were continued until the morning of surgery. After arrival to the operating room, patients were administered oxygen (0 2 ) by nasal prongs and monitoring of ECG (5 lead) with automated ST segment analysis and pulse oximetry was initiated (IntellivueMP 40, Philips Medical Systems, Germany). Under local anaesthesia and aseptic precautions, a 16-G intravenous cannula was inserted in the dorsum ofright hand, a 20-G intra-arterial cannula was introduced into the left radial artery for monitoring of the arterial pressure and obtaining arterial blood for analysis and right internal j ugularvein cannulation was done with appropriate size triple lumen cannula for CVP monitoring.
Patients were randomly divided into two groups of 50 patients each. Sufentanil group (S) received 0.5µg.kg 1 of sufentanil while Fentanyl group (F) received 0.5ìg.kg-1 of fentanyl as part of induction. All patients were induced with IV midazolam 0.05mg.kg -1 , a sleep dose of thiopentone sodium and IV vecuronium 0.1mg.kg -1 to facilitate endotracheal intubation. Patients were mechanically ventilated with tidal volume of 10 mLkgland respiratory rate of 10-12 / min using Pennon ventilator. Anaso gastric tube and nasal temperature probe were introduced. Diclofenac suppository was inserted. Anaesthesiawas maintained using oxygen, nitrous oxide, isoflurane (endtidal concentration 0.8-1%) and intermittent doses of vecuronium, and midazolam (1-5mg) before and after cardio-pulmonary bypass with goalto maintain stable haemodtnarmics. On cardiopulmonary bypass, an infusion of propofol was started at the rate of 4-5 mg.kg-.hr -1 for maintenance of anaesthesia. Additional doses ofopioid drug were given at the following steps of intense stimulus- at sternotomy, just before going `ON' CPB, coming `OFF' CPB and as& when required as perthe discretion of consultant anaesthetist. Patients from Sufentanil group received 0.1 µg.kg -1 of Sufentanil while patients from Fentanyl group received lµg.kg -l of fentanyl as additional dose. Total amount of sufentanil, fentanyl and midazolam administered during entire procedure was restricted to 1 gg.kg -1 , 6 pg.kg -1 and 5 mg respectively.
Inspired and expired gas concentration of O 2 , carbon dioxide (C0 2 ) and isoflurane were measured using anaesthetic gas monitoring system (anaesthesia gas monitor, Intellivue MP 40, Philips Medical Systems, Germany). Haemodynaimic parameters were maintained within 20% of the basal values with small boluses of IV nitro-glycerine/ sodium nitroprusside or IV ephedrine / phenylephrine and small boluses of IV metoprolol/ esmolol or atropine / glycopyrolate as required. Fillingpressures and fluid balance was maintained using lactated Ringers solution, 6%hydroxy-ethyl starch (HAES-steril, Fresenius Kabi) and blood and blood products as necessary. All patients were given infusion of 5% glucose with 10 units of insulin and 20 mEq of potassium for myocardial protection. Allthe cardiac surgeries were done using normothermic cardiopulmonary bypass.
If needed, infusions of dopamine/ isoprenaline/ adrenaline were used as inotrope while coming off bypass to maintain hemodynamics as per choice of anaesthetist and surgeon. Chest wound and chest tube insertion sites were infiltrated with 0.25% bupivacaine, in all patients.
At the end of surgery, patients were reversed and extubated ontable if
- Awake& alert
- Hemodynamically stable or minimal inotropic support
- Good tidal volumewith a respiratory rate of 10-24 breaths /min and good cough reflex.
Patients were mechanically ventilated when
- Deeply sedated patient
- Unstable hemodynamics or high dose inotropic support
The mode of ventilation in all patients was as follows
- Synchronised intermittent mandatory ventilation (SIMV) + Pressure support ventilation(PSV) (10 cm H 2 O)+Continuous positive airway pressure(CPAP) (3-5 cmH 2 O)
- Tidal volume(VT) 10 ml/kg& Respiratory rate(RR) 10 breaths /min
- To keep PaCO2 < 40 mmHg& pH 7.35– 7.45
Patients who were deeply sedated did not require additional sedatives or relaxants. Muscle relaxant was given only to patients with unstable hemo dynamics or heavy inotropic support to reduce work of breathing till haemodynarnically stable.
These ventilated patients were weaned by standard protocol when hemodynamically stable and were extubated with or without reversal depending on clinical signs of residual neuro -muscularblockade. Patients requiring prolonged ventilation due to surgical complications such as excessive drains, need for reexploration were excluded from the study. `Ventilatortime' was defined as time from arrival in ICU to extubation. Prolonged ventilation was defined as continued mechanical ventilation till next day morning or for more than 12 hours. All patients were given IV ondansetron 0.8 mg.kg -1 before extubation.
All patients were monitored in ICU postoperatively every 15 min for first hour and then every half an hour for 6 hours. Patients were asked to rate his/her pain (0-10) using VisualAnalogue Score 30 minutes after extubation and at next morning. IV tramadol was given (lmg.kg -l ) as rescue analgesia. In awake and extubatedpatients trtmadol was given if VAS> 4em or when patient demanded an analgesic. In mechanically ventilated patients, tram adol was given on clinical evidence of pain e.g. sweating, tachycardia, and hypertension.
Time of first dose oftramadolwas noted and the number of doses of tramadol between arrival in ICU and next morning were also noted. Patients were also asked for awareness during surgery, one hour after extubation and at next morning. Each patient was asked a standard set of questions. 1. What is the last thing you rememberbeforesurgery? Whatisthenextthing you remember? 3. Can you remember anything in between these two periods? 4. Did you have any dreams in between these two periods?
Sample size was calculated from previous study  on the basis of the anticipated difference in mean ventilationtirnebetweenthetwo groups. Assuming Type I error of 5% and Type II error of 20% (Power 80%), a 30% reduction was considered as clinically significant i.eo to detectdifference of 120minutes with standard deviation of 202 minutes. This required a sample size of 45 patients in each group. We used 50 patients in each group.
The data obtained in this study was analyzed using eitherunpaired`t' test or Pearson Chi-Square test according to different variables. Apvalue of less than 0.05 was considered significant.
| Results|| |
Atotalof 100patients were included in this prospective, randomized double blind study with 50 patients in each group. The two groups were comparable with regard to the demographic, preoperative and intraoperative data [Table 1] and [Table 2]
Allthe patients from both groups maintained stable haernodynamics throughout the surgery andthere was no statistical difference inthe vitalparameters between the two groups in the prebypass and postbypass period. There was no statistically significant difference in the number of patients needing inotropic support as well as the amount of inotropic support needed between the two groups in p ostbypass period.
The VAS score after extubation was 0.54+ 1.417 cm in Sufentanil group and 0.32±1.115 mm in Fentanyl group. The VAS score on the next day morning was 0.46 + 0.734 em and 0.42 +_0.642 cm in Sufentanil and Fentanyl groups respectively. These VAS scores were statistically comparable inthe two groups [Table 3]. The time to first dose of analgesic was significantly less (43.70 ± 51.145 min) in Sufentanil group as compared to Fentanyl group (70.68 ±65.538 min), however the total number of doses neededtill the next day morning were (1.60 ±0.571) in Sufentanil group and 1.44 ± 0.611 ) which were comparable statistically [Table 4].
Thirty-two out of fifty patients (64%) from the Sufentanil group could be extubated on table while from Fentanyl group, 19 patients (38%) could be extubated on table. Out of the 18 patients from Sufentanil group needing mechanical ventilation, the indication was deep sedation in 13 patients and heavy inotropic supportin 5patients. Out of the 3l patients from Fentanyl group needing mechanical ventilation, the indication was deep sedation in 20 patients and heavy inotropic support in 11 patients. The mode of ventilation in all patients was SIMV + PSV (10 crH2O) + CPAP (3-5 cmH2O) with TV 10 mUkg& RR 10 breaths /min. The average time on mechanical ventilation was 63.10 +99.994 minutes (Range-60-360 minutes) in Sufentanil group (36% patients) and 119.90+ 126.996 minutes (Range-25-360 minutes) in Fentanyl group (62% patients). None of the patients from either groups required mechanicalventilation exceeding 6 hours.
This difference in the number of patients needing mechanical ventilation and the ventilation time was statistically significant. However, this difference in ventilation time did not affect the duration of ICU stay which was 1.16 + 0.370 days in Sufentanil group and 1.14 + 0.351 days in Fentanyl group which was comparable [Table 5] and [Table 6].
Only one patient out of hundred belonging to Sufentanil group had awareness in the form of explicit memory of sound of sternotomy which lasted for few seconds. This patient was referred for psychological counseling.
None of the patients from either group had vomiting in postoperative period. One patient from Fentanyl group complained of mild nausea. This low incidence ofPONV could have been because: -
- All patients were given antiemetic prophylaxis prior to extubationin the form of Inj.Ondansetron O.Smg/kg.
- We did not use very high doses of opioids.
- Local anaesthetic infiltration of the surgicalsite reduced requirementof Inj.Tramadol
| Discussion|| |
Conventional practice of cardiac anaesthesia included high dose of opioid agents and prolonged post operative elective mechanical ventilation which in turn led to prolonged ICU stay and a protracted recovery. With the advent in surgical technique, warm bypass and anaesthesia; "Fast-Tracking" has become areality Fast -Tracking incorporates early extubation leadingto early mobilization and rehabilitation of patients 9 . Early extubation improves cardiac performance due to increased ventricular filling and reduces the incidence of postoperative pulmonary complications such as atelectesis.  Early mobilization has also been shown to improve patients' emotional wellbeing. Fast tracking also shortens ICU and effectively hospital stay resulting in reduction of costand betterresource utilization  . A growing body of evidence frommndomizedtrials has identified many anesthetic interventions in Fast Track cardiac anaesthesia (FTCA) that can improve outcome after cardiac surgery  . These include new short-acting hypnotic, opioid, and neuromuscular blockingdrugs. Fentanyl, Sufentanil, Remifentanil have been used effectively for FTCA in many studies. ,,, Sufentanil is 5-10 times more potent than Fentanyl and has a shorter duration of action than Fentanyl. We hypothesized that Sufentanil would shorten the time forextubation and ICU stay.
The purpose ofthis study was to compare the effects of two different opioid drugs Fentanyl and Sufentanil for cardiac surgery with respect to time to extubation, postoperative pain, hemodynamic stability and time to intensive care unit discharge and awareness during surgery. This was a prospective, randomized double blind study of 100 patients, 50 in each group labeled as GROUP `S' and GROUP `F' (another two patients were excluded from study because of prolonged ventilation >6 hrs secondary to surgical complication).
3µg.kg -1 of fentanyl was used during induction in `F' group. As sufentanil is 5- 10 times more potent than Fentanylwith halftheduration ofaction, loading dose of 0.5µgkg 1 of sufentanil was used for induction in 'S' group. For subsequent doses, lµg.kg 1 of fentanyl and 0.lpg.kg -1 of sufentanil was given respectively and the total dose fentanyl and sufentanil was restricted to 6 µg.kg -1 and 1ug.kg -1 respectively. We used low doses offentanyl and sufentanil compared to most studies in literature as the patient population comingto our setup with valvular or congenital heart disease belongs to low socio-economic society with poor general condition and this dose range was found to be adequate in pilot cases.
There was no statistically significant difference in the two groups with respectto age, weight, sex and in percent distribution of diagnos is amongthe two groups. Thus both the groups were comparable with respect to demographic parameters and surgicaldiagnosis. There was no statistically significant difference in the preoperative hemodynamic parameters making the two groups comparable in terms of baseline parameters.
Throughout the prebypass and postbypass period hemo dynamic parameters, SpO 2 andtemperature were monitored every 5 min. There was no statistically significant difference in these parameters in both the groups throughout prebypas s and p ostbyp ass period. There was no statistically significant difference between two groups in the number of patients needing ionotmpic support as well as the dose of ionotropic agent. Thus both Sufentanil and Fentanyl provide good hemodynamic stability.
More numberof patients in Sufentanil group (32 i.e.64%) could b e extubated on table and did not need mechanical ventilation as compared to 19 patients (i.e.38%)in Fentanylgroup. The meantime ofmechanical ventilation was 63.10 min in Sufentanil group as compared to 119.90 mm m Fentanyl group. Thus, time for mechanical ventilation in Sufentanil group was found to be reduced than that in Fentanyl group by an average of 57 minutes. This difference in the number of patients needing mechanical ventilation and duration of mechanical ventilation was statistically significant, indicating that extubation is achieved earlier in Sufentanil group. However, this difference did not affectthe length of ICU stay which was comparable in both groups.
Our results are similar to those of Butterworth, John MD; James, Robert Stat et al  who found that use of Sufentanil ratherthan Fentanylwas associated with a significant (p =0.045) reduction (of 1.9 h 95% CI, 0.04to 4.1 h) in duration oftime to extubation and no significant effect on ICU length of stay after extubation.
London MJ,  did recent observational study of Butterworth et alusing "mixed-effects" logistic regression modeling of a 40 hospital "benchmarking" dataset, and found little effect of use of Sufentanil (over Fentanyl) on ICU ortotal length of stay (after adjustment for patient risk and hospital level effects) but, Sufentaniluse was associated with a 1.9 hrt reduction in timeto extubation. Our results are similar.
In our study, no statistically significant difference was found between two groups with regards the VAS score after extubation and VAS on the next day morning or after 12 hours. In terms of the time for first dose of Tramadol required, it was found to be earlier with Sufentanil than Fentanyl 43.70±51.145 min vs.70.68±65.538 min; which is statistically significant. This is obvious as Fentanyl has longer duration of action compared to Sufentanil. But the total doses of Tramadol required in the postoperative period till next morning were similar. Engoren et al  studied patients undergoing cardiac surgery which were randomized to a Fentanyl-based, Sufentanil-based, or remifentanilbased anesthetic. Postoperative pain was measured at 30 min after extubation and at 6:30 AM on the first postoperative day. Pain scores at bothtimes were similar in allthree groups (P>0.05).
Cardiac anaesthesia is associated with higher incidence of awareness compared with other specialties. The incidence reported ranges from 1.1% to 23% depending upon the dose and agents used in anaesthesia. Possible reasons for this are, use of high opioid based techniques which reduces requirement of inhalational and intravenous anesthetic agents, almost unpredictable phamnacodynamics of anaesthetics underthe extracorporeal circulation especially in the rewarnning period and at the time of cessation of bypass, interpersonal and interracial differences in drug reactions, haemodilution, and b finding on foreign surface areas.
Dowd et al  did aprospective study on incidence of awareness in cardiac anaesthesia and reported an incidence of 0.3% in fast-track cardiac anaesthesia. This low incidence of awareness was related to the use of abalanced anesthetic technique involvingthe continuous administration of volatile (isoflurane) or intravenous (propofol) anaesthetic agents before, during, and after cardiopulmonary bypass. We too, used a balanced anesthetic technique.
In our study, one case from Sufentanil group had awareness during anaesthesia. The overall incidence of awareness in our study was 1.7% which was statistically insignificant. We did not use a BIS monitor and incidence of awareness in our study could have been probably avoided using BIS monitor.
In conclusion, both Sufentanil and fentanyl provide hemodynamic stability, early recovery and equal VAS scores m postoperative period, though fentanyl provides longer duration of postoperative analgesia. Sufentanil allows earlier extubation but duration of ICU stay is similar with both drugs. There is no statistically significant difference in incidence of awareness in the two groups. Thus, boththe agents can be used for FastTrack cardiac anaesthesia (FTCA), effectively. A use of BIS monitor is advisable to prevent awareness.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]