A novel application for bolus remifentanil: blunting the hemodynamic response to Mayfield skull clamp placement

Abstract

Objective:

Neurosurgery often requires skull immobilization with a Mayfield clamp, which often causes brief intense nociceptive stimulation, hypertension and tachycardia. Blunting this response may help prevent increased intracranial pressure, cerebral aneurysm or vascular malformation rupture, and/or myocardial stress. While various interventions have been described to blunt this response, no reports have compared administration of a propofol versus a remifentanil bolus.

Methods:

We retrospectively analyzed the hemodynamic response to Mayfield placement in over 800 patients who received a prior propofol or remifentanil bolus from 2004 to 2010.

Results:

Patients who received remifentanil experienced a 55% smaller increase in heart rate (p < 0.0001) and a 40% smaller increase in systolic blood pressure (p < 0.0001) after Mayfield placement than patients who received propofol. These data were retrospectively obtained from patients who were not randomized to receive remifentanil versus propofol, and hence these data could be subject to possible confounding. Nonetheless, these differences remained significant after multivariate analysis for possible confounding variables.

Conclusions:

Thus, a remifentanil bolus is more effective than a propofol bolus in blunting hemodynamic responses to Mayfield placement, and possibly for other short, intense nociceptive stimuli.

Keywords::

• Mayfield head clamp
• Neuroanesthesia
• Propofol
• Remifentanil

Transparency

Declaration of funding

Duke University Medical Center Department of Anesthesiology provided funding for this study.

Declaration of financial/other relationships

M.B., B.P.-B., J.G., T.J.H., M.L.J., C.O.B., D.S.W., and D.L.M. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.

CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships.

Acknowledgments

The authors thank Betsy Hale for assistance with data acquisition, Duke University Medical Center Department of Anesthesiology for providing funding, our neurosurgery colleagues, and the patients who underwent these surgeries.

This study was presented in part at the Society for Neuroscience in Anesthesiology and Critical Care 2012 annual meeting in Washington DC, USA.