Koray ALTUN, Çorman Pelin DİNÇER, E. Zeynep ETİ, F. Yılmaz GÖĞÜŞ

Alfentanil ve remifentanilin postoperatif kognitif fonksiyonlar üzerine etkilerinin karşılştırılması

Amaç: Çalışmanın amacı elektif şartlarda mastektomi operasyonu geçirecek hastalarda propofol ile birlikte uygulanan alfentanil ve remifentanilin intraoperatif hemodinamik parametreler, derlenme ve erken postoperatif dönemdeki kognitif fonksiyonlar üzerine olan etkilerini karşılaştırmaktır. Yöntem: ASA I-III grubunda, 20-70 yaş arasında, mastektomi yapılacak 60 hasta randomize olarak iki gruba ayrıldı. Ameliyattan bir gece önce standart mini mental test (SMMT) uygulandı. Anestezi indüksiyonu her iki grupta da 2 mg kg-1 propofol ile sağlandı. Birinci gruba alfentanil 10 µg kg-1 bolus sonrası 1,5 µg kg-1 dk-1 infüzyon; 2. gruba remifentanil 1 µg kg-1 bolus sonrası 0,2 µg kg-1 dk-1 infüzyon uygulandı. idamede her iki gruba propofol infüzyonu ilk 10 dakikada 12 mg kg-1st-1, ikinci 10 dakikada 9 mg kg-1st-1 daha sonra 6 mg kg-1st-1 ’ ten uygulandı. Cerrahinin sonlanmasından 15 dakika önce alfentanil infüzyonu, 5 dk. önce remifentanil infüzyonu, cerrahi bitiminde propofol infüzyonu sonlandırıldı. Postoperatif ilk 15 dakika 5 dakika aralarla hemodinamik veriler, sedasyon skorları ve yan etkiler değerlendirildi. Postoperatif 1. ve 3. saatlerde SMMT uygulandı. istatistiksel analiz tekrarlayan ölçümlerde iki-yönlü ANOVA, gruplararası karşılaştırmada tek-yönlü ANOVA ve posthoc test olarak Student-Newman-Keuls testi ile yapıldı (p

Comparison of the effects of alfentanil and remifentanil on postoperative cognitive functions

Objective: The aim of this study was to investigate the effects of alfentanil and remifentanil with propofol on peroperative hemodynamic parameters, recovery and cognitive functions in early postoperative period of the patients undergoing elective mastectomy. Method: Sixty patients, aged between 20-70 years, ASA status I-III, undergoing mastectomy were randomised into two groups (n=30). Standardized mini mental test (SMMT) was performed to all patients the night before the surgery. In all patients induction of anesthesia was performed by 2 mg kg-1 propofol. In the 1st group after 10 µg kg-1 iv bolus, alfentanil was infused 1.5 µg kg-1 min-1 , in the 2nd group after 1 µg kg-1 iv bolus, remifentanil was infused 0.2 µg kg-1 min-1 . For anesthesia maintenance propofol infusion was used in all patients, first 10 minutes 12 mg kg-1 h-1 , the 2nd 10 minutes 9 mg kg-1 h-1 thereafter 6 mg kg-1 h-1 . Alfentanil and remifentanil infusions were discontinued 15 minutes and 5 minutes before the end of surgery respectively and propofol infusion was stopped at the end of the surgery. Hemodynamic parameters, sedation scores and side effects were evaluated during postoperative 15 minutes with 5 minute intervals. SMMT was performed at the 1st and 3rd postoperative hours. Statistical analysis were made with t- wo-way ANOVA for comparison of repeated measurements, with one-way ANOVA for comparisons between the groups and with Student-Newman-Keuls test for posthoc comparison (p<0.05). Results: The sedation scores of remifentanil group in postoperative 5th and 10th minutes are significantly lower than those of alfentanil group (p<0.05). Although preoperative SMMT values of groups were similar, the scores of alfentanil group were significantly lower than those of remifentanil group in the 1st hour postoperatively (p<0.001). Conclusion: We concluded that in patients undergoing mastectomy, remifentanil infusion could be preferred as the drug of choice during TIVA with propofol rather than alfentanil as cognitive functions and level of consciousness are less disturbed during early postoperative period.

PDF

___

1. Hanning CD. Postoperative cognitive dysfunction. Br J Anaesth 2005; 95: 82-7.
2. Karaca S. Postoperatif Kognitif Fonksiyon Bozuklukları. TARK 2004 Özet Kitabı, 57.
3. Öğün CÖ, Topal A. Remifentanil, sevofluran, azot protoksit anestezisinde propofol ve tiyopentonun orta ve ileri yaşlardaki kadınlarda derlenme ve erken kognitif fonksiyonlara etkisi. Türk Anest Rean Cem Mecmuas› 2002; 30: 209-17.
4. Johnson T, Monk T, Rasmussen LS, Abildstorm H. Postoperative cognitive dysfunction in middle aged patients. Anesthesiology 2002; 96: 1351-7.
5. Calderon E, Pernia A. A comparison of two constant dose continuous infusions of remifentanil for severe postoperative pain. Anesth Analg 2001; 92: 715-9.
6. Aydemir Ö, Köroğlu E. Psikiyatride Kullanılan Klinik Ölçekler. 3. Baskı. Ankara: Hyb Yayıncılık; 2007, 291-3.
7. Schüttler J, Albrecht S, Breivik H, et al. A comparison of remifentanil and alfentanil in patients undergoing major abdominal surgery. Anaesthesia 1997; 52: 307-17.
8. Cartwright DP, Kvalsvik O, Cassuto J, et al. A randomized, blind comparison of remifentanil and alfentanil during anesthesia for outpatient surgery. Anesth Analg 1997; 85: 1014-9.
9. Hogue CW, Bowdle TA, O’Leary C, et al. A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient surgery. Anesth Analg 1996; 83: 279-85.
10. Caverni V, Rosa G, Pinto G. Hipotensive anesthesia and recovery of cognitive function in long term craniofacial surgery. J Craniofac Surg 2005; 16: 531-6.
11. Moller JT, Cluitmans P, Rasmussen LS, et al. Long term postoperative cognitive dysfunction in elderly. ISPOCD-1 study. Lancet 1998; 351: 857-61.
12. Tune LE, Holland A, Folstein MF. Association of postoperative delirium with raised levels of anticholinergic drugs. Lancet 1982; 2: 651-3.
13. Başgül E, Çeliker V. Elektrokonvülzif tedavide anestezi yaklaşımı. Türk Psikiyatri Dergisi. 2004; 15: 225-35.
14. Fragen RJ, Randel GI, Librojo BS, et al. The interaction of remifentanil and propofol to prevent response to tracheal intubation at the start of surgery for outpatient knee arthroscopy. Anesthesiology 1994; 81: A376.
15. Hughes MA, Glass PS, Jacobs JR. Context-sensitive half time in multicompartment pharmacokinetic models for intravenous anesthetic drugs. Anesthesiology 1992; 76: 334-41.
16. Philip BK, Scuderi PE, Chung F, et al. Remifentanil compared with alfentanil for ambulatory surgery using total intravenous anesthesia. Anesth Analg 1997; 84: 515-21.
17. Papaioannou A, Fraidakis O, Michaloudis D, et al. The impact of the type of anaesthesia on cognitive status and delirium during the first postoperative days in elderly patients. Eur J Anaesthesiol 2005; 22: 492-9.
18. Linstedt U, Meyer O, Kropp P, et al. Serum concentration of S-100 protein in assessment of cognitive dysfunction after general anesthesia in different types of surgery. Acta Anaesthesiol Scand 2002; 46: 384-9.
19. Rasmussen LS, Christiansen M, Rasmussen H, et al. Do blood concentrations of neuron specific enolase and S-100 beta protein reflect cognitive dysfunction after abdominal surgery? Br J Anaesth 2000; 84: 242-4.
20. McDonagh DL, Mathew JP, White WD, et al. Cognitive function after major non-cardiac surgery, Apolipoprotein E4 Genotype, and biomarkers of brain injury. Anesthesiology 2010; 112: 852-9.