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Intraoperative Opioids for Thoracic Surgery: Impact of Remifentanil and Fentanyl on Post-operative Pain Control and Morphine Consumption

Background: Remifentanil could be the opioid of choice in fast track surgery for the unique pharmacokinetic properties of fast onset time of action, a predictable and rapid recovery and facilitation of early extubation. According to the literature, intraoperative use of remifentanil may be associated with postoperative hyperalgesia and increased postoperative opioid consumption, in particular when administered in high doses. For this reason, we decided to investigated the post-operative pain and the total use of opioids in resective lung operation in fast track surgery independently of intraoperative opioid (fentanyl or remifentanil), local regional anesthesia (intercostal, nerve block, paravertebral nerve block, wound infiltration) and the management of post-operative pain (morphine elastomer or Patient Controlled Analgesia).

Keywords: morphine consumption, pain control, remifentanil.

Materials/Methods: We perspectively observed 30 patients underwent a resective lung surgery (atypical resection, lobectomy or segmentectomy), collected the Numeric Rating Scale (NRS) for static and dynamic pain at 6, 24 hours and the worst NRS in 48 postoperative hours. We also examined the consumption of opioid in the intraoperative (bolus) and postoperative phase, at 24 and 48 hours after surgery.

Results: 15 patients underwent fentanyl based general anaesthesia (GA) and the other half underwent remifentanil based GA. The two groups can ben consider homogeneous for independent parameters such as gender, age, weight, height, BMI, ASA class, surgical time and type of resection. They are not homogeneous for postoperative pain management: the elastomeric pump was used for only 3 patients in remifentanil group and for 11 patients in fentanyl group. Although intraoperative morphine’s bolus was much more considerable in remifentanil group (P = 0,0019), the total opioids consumption in the first and second post-operative days were not significantly different in the two groups (P24h=0,6312; P48h=0,3051). Moreover, we analyzed the NRS pain score at 6, 24, 48 h after surgery for which no statistic difference was found.

Conclusion: The use of intraoperative remifentanil seems not to be associated with a clinical NRS variation or with an increased use of postoperative opioids when compared with the use of intraoperative fentanyl (Figure 1, Figure 2). We noticed an increased use of intraoperative morphine in the remifentanil group, furthermore the total opioids dosage seems to be equal in both group. Even if patients in fentanyl group had more continuous elastomeric pump (P= 0,0104) we didn’t notice at 6, 24 and 48 hours an enlarged consumption of morphine (Figure 3).

Figure 1: Static NRS at 1,6,24, 48 h Figure 2: Dynamic NRS at 1,6,24, 48 h

Figure 3: Total Opioids Consumption

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