Comparison of Fentanyl, Remifentanil, Sufentanil and Alfentanil in Combination with Propofol for General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Author(s): Kannan Sridharan*, Gowri Sivaramakrishnan

Journal Name: Current Clinical Pharmacology

Volume 14 , Issue 2 , 2019

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Graphical Abstract:


Abstract:

Background: Opioid analgesics are commonly used along with propofol during general anesthesia. Due to the dearth of data on the quality of anesthesia achieved with this combination, the present meta-analysis was carried out.

Methods: Electronic databases were searched for appropriate studies using a suitable search strategy. Randomized clinical trials comparing the combination of remifentanil/sufentanil/alfentanil with propofol with fentanyl and propofol, were included. The outcome measures were as follows: total propofol dose to achieve the desired general anesthesia; time of onset and duration of general anesthesia; depth of general anesthesia; and recovery time (time for eye-opening and time taken for extubation). Risk of bias was assessed and Forest plots were generated for eligible outcomes. The weighted mean difference [95% confidence intervals] was used as the effect estimate.

Results: Fourteen studies were included in the systematic review and 13 were included in the metaanalysis. Statistically significant differences were observed for remifentanil in comparison to fentanyl when combined with propofol: Propofol dose (in mg) -76.18 [-94.72, -57.64]; time of onset of anesthesia (min) -0.44 [-0.74, -0.15]; time taken for eye-opening (min) -3.95 [-4.8, -3.1]; and time for extubation (min) -3.53 [-4.37, -2.7]. No significant differences were observed for either sufentanil or alfentanil about the dose of propofol required and due to scanty data, pooling of the data could not be attempted for other outcome measures for either sufentanil or alfentanil.

Conclusion: To conclude, we found that remifentanil has a statistically significant anesthetic profile than fentanyl when combined with propofol. Scanty evidence for both alfentanil and sufentanil precludes any such confirmation.

Keywords: Opioids, anesthesia, propofol related pain, fentanyl induced cough, alfentanil, sufentanil.

[1]
McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs 2003; 17(4): 235-72.
[http://dx.doi.org/10.2165/00023210-200317040-00003] [PMID: 12665397]
[2]
Jalota L, Kalira V, George E, et al. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ 2011; 342: d1110.
[3]
Morton NS, Johnston G, White M, Marsch BJ. Propofol in paediatric anaesthesia. Paediatr Anaesth 1992; 2: 89-97.
[http://dx.doi.org/10.1111/j.1460-9592.1992.tb00182.x]
[4]
Marik PE. Propofol: therapeutic indications and side-effects. Curr Pharm Des 2004; 10(29): 3639-49.
[http://dx.doi.org/10.2174/1381612043382846] [PMID: 15579060]
[5]
Peng PWH, Sandler AN. A review of the use of fentanyl analgesia in the management of acute pain in adults. Anesthesiology 1999; 90(2): 576-99.
[http://dx.doi.org/10.1097/00000542-199902000-00034] [PMID: 9952166]
[6]
Kizilcik N, Menda F, Bilgen S, Keskin O, Koner O. Effects of a fentanyl-propofol mixture on propofol injection pain: a randomized clinical trial. Korean J Anesthesiol 2015; 68(6): 556-60.
[http://dx.doi.org/10.4097/kjae.2015.68.6.556] [PMID: 26634078]
[7]
Sedighinejad A, Naderi Nabi B, Haghighi M, et al. Propofol is effec-tive to depress fentanyl-induced cough during of anesthesia. Anesth Pain Med 2013; 2(4): 170-3.
[http://dx.doi.org/10.5812/aapm.8383] [PMID: 24223355]
[8]
Higgins JPT, Green S. (editors). Cochrane Handbook for Systematic Reviews of Interventions. 5.1.0 edition. Available from www.cochrane-handbook.org (Accessed on 21 Aug 2016).
[9]
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62(10): 1006-12.
[http://dx.doi.org/10.1016/j.jclinepi.2009.06.005] [PMID: 19631508]
[10]
Hui JKL, Critchley LAH, Karmakar MK, Lam PKK. Co-administration of alfentanil-propofol improves laryngeal mask airway insertion compared to fentanyl-propofol. Can J Anaesth 2002; 49(5): 508-12.
[http://dx.doi.org/10.1007/BF03017932] [PMID: 11983670]
[11]
Manninen PH, Balki M, Lukitto K, Bernstein M. Patient satisfaction with awake craniotomy for tumor surgery: a comparison of remifentanil and fentanyl in conjunction with propofol. Anesth Analg 2006; 102(1): 237-42.
[http://dx.doi.org/10.1213/01.ANE.0000181287.86811.5C] [PMID: 16368836]
[12]
Haytural C, Aydınlı B, Demir B, et al. Comparison of propofol, propofol-remifentanil and propofol-fentanyl admin-istrations with each other used for the sedation of patients to undergo ERCP. BioMed Res Int 2015.2015465465
[http://dx.doi.org/10.1155/2015/465465] [PMID: 26576424]
[13]
Yong-hua YAO, Zi-lin WU. Clinical investigation of total intravenous anesthesia with remifentanil and propofol for co-lonoscopy in the elderly. J First Mil Med Univ 2005; 25: 715-7.
[14]
Srivastava U, Mishra AR, Sharma S, et al. Anaesthesia for direct laryngoscopy with propofol and fentanyl or sufentanil. Indian J Otolaryngol Head Neck Surg 2008; 60(4): 314-6.
[http://dx.doi.org/10.1007/s12070-008-0106-x] [PMID: 23120572]
[15]
Ryu J-H, Kim J-H, Park K-S, Do S-H. Remifentanil-propofol versus fentanyl-propofol for monitored anesthesia care during hysteroscopy. J Clin Anesth 2008; 20(5): 328-32.
[http://dx.doi.org/10.1016/j.jclinane.2007.12.015] [PMID: 18761238]
[16]
Lysakowski C, Dumont L, Pellegrini M, Clergue F, Tassonyi E. Effects of fentanyl, alfentanil, remifentanil and sufentanil on loss of consciousness and bispectral index during propofol induction of anaesthesia. Br J Anaesth 2001; 86(4): 523-7.
[http://dx.doi.org/10.1093/bja/86.4.523] [PMID: 11573626]
[17]
Kwak HJ, Kim JY, Kwak YL, Park WS, Lee KC. Comparison of a bolus of fentanyl with an infusion of alfentanil during target-controlled propofol infusion in third molar extraction under conscious sedation. J Oral Maxillofac Surg 2006; 64(11): 1577-82.
[http://dx.doi.org/10.1016/j.joms.2005.11.112] [PMID: 17052581]
[18]
Ho WM, Yen C-M, Lan C-H, et al. Comparison between the recovery time of alfentanil and fentanyl in balanced propofol sedation for gastrointestinal and colonoscopy: a prospective, randomized study. BMC Gastroenterol 2012; 12: 164.
[http://dx.doi.org/10.1186/1471-230X-12-164] [PMID: 23170921]
[19]
Takayama A, Yamaguchi S, Ishikawa K, et al. Recovery of psychomotor function after total intravenous anesthesia with remifentanil-propofol or fentanyl-propofol. J Anesth 2012; 26(1): 34-8.
[http://dx.doi.org/10.1007/s00540-011-1266-5] [PMID: 22048284]
[20]
Wilhelm W, Biedler A, Huppert A, et al. Comparison of the effects of remifentanil or fentanyl on anaesthetic induction characteristics of propofol, thiopental or etomidate. Eur J Anaesthesiol 2002; 19(5): 350-6.
[http://dx.doi.org/10.1097/00003643-200205000-00006] [PMID: 12095015]
[21]
Ahonen J, Olkkola KT, Hynynen M, et al. Comparison of alfentanil, fentanyl and sufentanil for total intravenous anaesthesia with propofol in patients undergoing coronary artery bypass surgery. Br J Anaesth 2000; 85(4): 533-40.
[http://dx.doi.org/10.1093/bja/85.4.533] [PMID: 11064610]
[22]
Coskun D, Celebi H, Karaca G, Karabiyik L. Remifentanil versus fentanyl compared in a target-controlled infusion of propofol anesthesia: quality of anesthesia and recovery profile. J Anesth 2010; 24(3): 373-9.
[http://dx.doi.org/10.1007/s00540-010-0898-1] [PMID: 20229001]
[23]
Del Gaudio A, Ciritella P, Perrotta F, et al. Remifentanil vs fentanyl with a target controlled propofol infusion in patients undergoing craniotomy for supratentorial lesions. Minerva Anestesiol 2006; 72(5): 309-19.
[PMID: 16675939]
[24]
Tedders KM, McNorton KN, Edwin SB. Efficacy and safety of analgosedation with fentanyl compared with traditional sedation with propofol. Pharmacotherapy 2014; 34(6): 643-7.
[http://dx.doi.org/10.1002/phar.1429] [PMID: 24753262]
[25]
Weisenberg M, Sessler DI, Tavdi M, et al. Dose-dependent hemodynamic effects of propofol induction following brotizolam premedication in hypertensive patients taking angiotensin-converting enzyme inhibitors. J Clin Anesth 2010; 22(3): 190-5.
[http://dx.doi.org/10.1016/j.jclinane.2009.07.008] [PMID: 20400005]
[26]
Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000; 90(4): 963-9.
[http://dx.doi.org/10.1213/00000539-200004000-00035] [PMID: 10735808]
[27]
Goyagi T, Tanaka M, Nishikawa T. Fentanyl decreases propofol requirement for laryngeal mask airway insertion. Acta Anaesthesiol Scand 2003; 47(6): 771-4.
[http://dx.doi.org/10.1034/j.1399-6576.2003.00123.x] [PMID: 12803598]
[28]
Kim JE, Min SK, Chae YJ, Lee YJ, Moon BK, Kim JY. Pharmacological and nonpharmacological prevention of fentanyl-induced cough: a meta-analysis. J Anesth 2014; 28(2): 257-66.
[http://dx.doi.org/10.1007/s00540-013-1695-4] [PMID: 23958914]
[29]
Beers R, Camporesi E. Remifentanil update: clinical science and utility. CNS Drugs 2004; 18(15): 1085-104.
[http://dx.doi.org/10.2165/00023210-200418150-00004] [PMID: 15581380]
[30]
Kawano H, Manabe S, Matsumoto T, et al. Comparison of intraoperative blood loss during spinal surgery using either remifentanil or fentanyl as an adjuvant to general anesthesia. BMC Anesthesiol 2013; 13(1): 46.
[http://dx.doi.org/10.1186/1471-2253-13-46] [PMID: 24304964]
[31]
Beers RA, Calimlim JR, Uddoh E, Esposito BF, Camporesi EM. A comparison of the cost-effectiveness of remifentanil versus fentanyl as an adjuvant to general anesthesia for outpatient gynecologic surgery. Anesth Analg 2000; 91(6): 1420-5.
[http://dx.doi.org/10.1097/00000539-200012000-00022] [PMID: 11093992]


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Article Details

VOLUME: 14
ISSUE: 2
Year: 2019
Page: [116 - 124]
Pages: 9
DOI: 10.2174/1567201816666190313160438

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