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Literature Review

The Effect of Remifentanil or Fentanyl on Postoperative Vomiting and Pain in Children Undergoing Strabismus Surgery

Eltzschig H, Schroeder T, Eissler J, et al. Anesthesia & Analgesia 2002;94:1173-7.

Review: The goal of the study was to examine the effect of IV remifentanil versus fentanyl on postoperative vomiting (POV) and postoperative pain in children undergoing strabismus surgery under general anesthesia. The prospective, double-blinded study consisted of 81 patients, aged 2 12 years (42 boys and 39 girls), American Society of Anesthesiologists physical status I or II, undergoing elective strabismus surgery. Exclusion critieria for this study were patients with a history of POV, motion sickness, or at risk for malignant hyperthermia. Patients were randomized to receive either remifentanil or fentanyl during the procedure.

Premedication with oral midazolam 0.4 mg/kg, to a maximum dose of 10 mg was administered to all of the children in the study. An intravenous catheter was placed prior to mask induction. Remifentanil was given as a bolus 1 mcg/kg IV over 2 minutes, and was followed by a continuous infusion of 0.2 mcg/kg/min. After incision, the infusion rate was decreased to 0.1 mcg/kg/min, and remained at this rate until closure of the conjunctiva. At this point in time, the infusion was discontinued. In the other group of patients, fentanyl was administered as a bolus of 2 mcg/kg prior to induction, and repeated every 45 minutes at 1 mcg/kg during the surgery. Following the bolus of remifentanil or fentanyl, an inhalation induction consisting of oxygen and sevoflurane (inspired concentration of 6% until loss of consciousness) was the technique of choice. Rocuronium 0.6 mg/kg IV was used to facilitate endotracheal intubation. All patients received acetaminophen 10 mg/kg per rectum following induction of anesthesia. Sevoflurane at an end-tidal concentration of 2.5% with air and oxygen were used for anesthesia maintenance. An antiemetic was not administered during the surgery. Sevoflurane was discontinued after closure of the conjunctiva. Muscle relaxation was not reversed in any patient, because sustained tetanus greater than 5 seconds was present.

Following extubation, patients were transferred to the PACU and monitored there for at least one hour, until discharge criteria was met. In the PACU, pain scores were recorded at 15, 30, 45, and 60 minutes. If a pain score greater than 3 was recorded, the patient received an additional dose of acetaminophen 10 mg/kg per rectum. For pain scores greated than 5, the child received 0.4% oxybuprocaine eye drops. POV episodes were followed for 25 hours after surgery. It is the practice in their institution to hospitalize patients after strabismus surgery for greater than 24 hours. Following final analysis of the data, this study showed that the incidence of POV was similar for the two groups (Remifentanil, 49% vs Fentanyl, 48%).

On the contrary, the number of POV episodes with remifentanil compared with fentanyl (0.95 vs 2.2 episodes) were less frequent. Initially, pain scores were found to be higher in the Remifenanil group.

Comments: This study is the first to compare the effect of remifentanil and fentanyl on POV episodes and pain in children undergoing strabismus surgery. The results of this study are worth consideration, and you may want to incorporate the information into your own practice. There are several issues that the reader of this study should keep in mind. In this study, the children were hospitalized for greater than 24 hours after the surgery. I equate this with somewhat of a "controlled environment." I believe, that for the majority of us, strabismus repair in children, would be performed on an out-patient basis. The biggest question I have with this study, is whether or not the results would differ if the children had been discharged to home on the day of surgery rather than remain hospitalized. I leave you with this question to ponder.

Reviewed by: Cheryl K. Gooden, MD #include ./footer_include.iphtml